In this case, despite repeated encounters with health care providers, the patient's severe peripheral arterial disease was misdiagnosed, and this cognitive error led to a serious adverse event. The vascular surgeons who cared for the patient believed the patient's chronic burning pain was likely due to progressive peripheral arterial disease and not to a peripheral neuropathy. Unfortunately, due to ischemia (lack of blood flow from the arterial disease) of his leg, he developed multiple infections postoperatively and ultimately required an above-the-knee amputation. The patient required emergent bypass surgery of the left leg by vascular surgery. A computed tomography angiogram revealed complete occlusion of the left superficial femoral artery secondary to atherosclerotic peripheral arterial disease. On exam his left lower leg was dusky in color with extreme tenderness to palpation and his pulses could not be palpated. During these visits, a complete extremity exam was not performed or documented, and the complaint was repeatedly attributed to his prior diagnosis of peripheral neuropathy.Īfter multiple visits to his PCP and urgent care over a 2-month period, the patient presented to the emergency department with worsening symptoms. Each time he was referred to podiatry, but he never went to any podiatry appointments. The patient presented four more times to his PCP and twice to urgent care with a similar complaint of left foot pain. The PCP attributed the patient's pain and numbness to a peripheral neuropathy and referred him to podiatry. The exam was notable for loss of sensation to his knee and a foot drop secondary to his prior stroke, but his pulses were intact with no other abnormalities noted. Review system-based interventions that can help reduce diagnostic errors.Ī 61-year-old man with a history of stroke initially presented to his primary care physician (PCP) complaining of burning pain and numbness in his left foot for one month.Describe steps to improve cognitive awareness of diagnostic errors.List some of the cognitive biases that contribute to anchoring.Appreciate that diagnostic errors are common in primary and ambulatory care.
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