This document discusses cognitive biases that can impact clinical decision making, including availability bias, framing effect, and anchoring. It then presents several case studies and notes key details from the patient histories, physical exams, and lab results. The document emphasizes the importance of follow up to help prevent cognitive shortcuts from leading to harm by allowing clinicians to reconsider cases from new perspectives with additional data.

1. Further Observations on Decision
Making-2019
Blaise L. Congeni M.D.

2. Cognitive Pitfalls
• Availability:
– emphasis on things that come to mind easily
– Common events occur commonly
– “if you hear hoof beats…”
– Easily remembered or recently encountered
• Framing effect
– decisions are influenced by how information is
presented, or framed

3. 18 yo with 1 week of periorbital edema
• HX:
– Fatigue, intermittent headaches
– No fever, mild scratchy throat
– Swelling around eyes
– Friend at school with mono
• PE
– Non-ill appearing
– Asymmetric Swelling around the eyes, R>L
– Mild anterior cervical nodes

4. 18 yo with 1 week of periorbital edema
• HX:
– Fatigue, intermittent headaches
– No fever, mild scratchy throat
– Swelling around eyes
– Friend at school with mono
• PE
– Non-ill appearing
– Asymmetric Swelling around the eyes, R>L
– Mild anterior cervical nodes

5. Cognitive pitfalls
• Anchoring:
– stick with initial
impression
– reluctance to pursue
alternative possibilities

6. Cognitive Pitfalls
• Availability:
– emphasis on things that come to mind easily
– Common events occur commonly
– “if you hear hoof beats…”
– Easily remembered or recently encountered
• Framing effect
– decisions are influenced by how information is
presented, or framed

7. 7 YO, WF
• Presents with 5 days of cellulitis on abdomen,
treated with amoxicillin/clav without
improvement.
• Crp 30, WBC 8.4, plat-120, 7 bands, 65 segs, cpk-
25.
• U/S- 1.7 cm abscess under umbilicus, 48 hours of
thrombocytopenia, and she remained febrile 72
hours. She was treated initially with clindamycin,
and Vancomycin and ceftriaxone added.

9. 6 mo with 8 days of fever
• Fever up to 104 F for 8 days
• Mild cough, 6 sibs with cough, unimmunized
• CXR “Findings concerning for upper lobe
pneumonia, likely on the background of viral
process or reactive airways disease.”
• Unresponsive to Augmentin
• Normal exam

11. Labs
• WBC 19.2; plts 579 K; Hb 10.5
• ALT 35; Albumin 2.9
• CRP 11.2
• Blood culture pending
• Respiratory PCR panel:
– Rhinovirus/enterovirus positive

12. 18 YO ADHD
• 1 week HO moving the left side of his face
• No rash or or other recent illness, but he has
had some palpitations.(no fainting/dizziness)
• Vs: T-37, P-60.

13. Lyme Disease Western Blot (MAYO)
Order: 84696775
Status: Final result Visible to patient: No
(Not Released)
Component
Ref Range & Units 1mo ago
Lyme IgG WBlot (Mayo)
Negative NA Positive
Lyme IgG detected against
kDa SEE BELOW
Comment: p93,p66,p45,p41,p39,p23,p18
Lyme IgM WBlot (Mayo)
Negative NA Positive
Lyme IgM detected against
kDa p41,p39,p23
Lyme WBlot Interp (Mayo)
NA SEE BELOW
Comment: Consistent with active or previous
infection for B.
burgdorferi.
IgM blot criteria is of diagnostic utility only
during the
first 4 weeks of early Lyme disease

15. Lyme Disease Tips
Incidence
We are in the middle of tick season and with that comes concerns forLyme Disease. Overthe past few
years the incidence of Lyme disease in Ohio has increased. Despite the increasewe are not considered a
highly endemicstate (ourincidenceis 2 per100,000 population compared to 10 per100,000 which is
considered highly endemic). Although Ohio’s incidenceis low, the rate is sufficient to routinely include
Lyme Disease in the differential diagnosis of patients during tick season with:
Clinical
1) Rash characteristicof erythemamigrans (early localized and early disseminated infection)
2) Bell’s palsy (early disseminated infection)
3) Carditis, usually an AV block (early disseminated infection)
4) Asepticmeningitis (early disseminated infection)
5) Arthritis, especially involving the large joints (late disseminated infection: note that late
manifestation may appearoutside the months when ticks are active)
Testing
Patients with clinical evidenceof early localized Lyme Disease based on erythemamigrans requireno
testing and should be treated empirically.
All otherforms of Lyme Disease should be confirmed with serologictesting.
When testing forLyme Disease order: “Lyme Disease serology”. This orderincludes IgGand IgM and will
automatically reflex to the confirmatory Western Blot if the serology is positive.
Treatment
The Redbook now recommends using doxycycline (4.4mg/kg/day divided into 2doses with a max of 200
mg/day) as the first choice fortreating patients diagnosed with Lyme Diseaseregardless of age.
Amoxicillin, however, remains an acceptable choice.
Prophylaxis Advice
Advice forpatients exposed to ticks within Ohio
1. The difference between the rash of Lyme Disease (erythemamigrans)and alocalized allergic
reaction. The erythemamigrans rash usually appears aweek ormore after the tick bite (range of
3 – 32 days). It is a slowly expanding red lesion (sometimes with central clearing)that measures
at least 2 inches across and is normally painless and non-itchy. Local allergicreactions are
smallerareas of redness that are often itchy and appearwithin the first day or two of the tick
bite.
2. Should I get antibiotics afteratick bite?
No. Ohio is not a high incidence state. Forticks bites that occurwithin Ohio, no antibiotic
prophylaxis is recommended.
Prophylaxis may be considered fortick bites acquired in high incidencestates such
as Pennsylvaniaif an engorged tick has been present for36 hours or more AND if prophylaxis is
started with 72 hours of removing the tick.

25. 8 YO W,F
• H/O CAP in last 6weeks ago, presents now
with emesis and fever., 7-10 days duration.
• Weight loss of 30 lbs, ROS positive for cough
and poor po.
• Patient seen at OSH 6 weeks ago with 1 week
of cough and fever. CXR showed patchy
consolidation with small left pl effusion.
• Patient treated with ceftin, and instructed to
have child “return …if she is worse in any way”

27. Follow-up covers a multitude of sins
• Follow up may help prevent cognitive
shortcuts from causing harm
– Helps clinicians to reboot and reconsider the
patient from an alternative perspective
– Helps offset the availability error by providing an
opportunity to consult sources,
– Helps mitigate the anchoring error by providing
more distance from initial impressions
– New data