Lessons in clinical reasoning - pitfalls, myths, and pearls: how search satisfying can keep eyes crossed

Missed opportunities for diagnostic excellence are common and can lead to delayed diagnoses and initiation of treatment. Medical teams incorporate many elements into the diagnostic process, including patient factors, medical knowledge, data gathering, care environment, subspecialized personnel, and hospital processes. A case-based discussion describes how search satisfying - the tendency to stop searching once something has been found - and authority gradients can lead to delays in diagnosis.

A 2-year-old girl repeatedly presents to the emergency department with vomiting and periorbital swelling progressing to esotropia, initially found to have normal short-sequence MR brain imaging. After nonspecific labs and reassuring initial imaging, ophthalmologic consultation obtained during the child's third emergency department visit proposed plausible diagnoses of benign post-viral esotropia or decompensated esotropia. When her exam worsened at ophthalmology clinic follow up, she was referred back to the emergency department for complete MR brain and orbit imaging leading to a diagnosis of bilateral orbital myositis.

Examining the diagnostic process through integrated commentary, this case emphasizes the importance of recognizing limitations of short-sequencing advanced imaging and continuing the diagnostic pursuit in collaboration with consultants. A fishbone diagram visually demonstrates the factors that lead to a missed opportunity for diagnostic excellence. The case concludes with clinical teaching points in addition to a pitfall, myth, and pearl specific to search satisfying and authority gradients.