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Lessons in clinical reasoning: a case of a boy who continued crying after falling
Mizuka Fu1, Toshiki Nakamura1, Shun Kishibe2
1Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan.
Insights
Delayed diagnosis in infants can occur due to vague symptoms. Thorough assessment and considering family concerns are crucial for accurate pediatric trauma diagnosis.
Area of Science:
- Pediatric Emergency Medicine
- Trauma Care
- Diagnostic Accuracy
Background:
- Diagnostic errors are common in emergency departments, especially in pediatric cases.
- Evaluating trauma in preverbal infants presents challenges due to their inability to communicate symptoms.
- This case highlights a misdiagnosis of irritability in an infant following minor head trauma.
Purpose of the Study:
- To present a case of delayed diagnosis in pediatric trauma.
- To identify factors contributing to diagnostic errors in preverbal infants.
- To emphasize the importance of comprehensive evaluation in pediatric emergency care.
Main Methods:
- Case report of a 1-year-6-month-old boy with irritability after head trauma.
- Initial misdiagnosis attributed irritability to URTI and environmental stress.
- Root cause analysis using a fishbone diagram to identify diagnostic delay factors.
Main Results:
- The infant was discharged but returned with a femoral fracture.
- Contributing factors included vague pediatric trauma presentation, cognitive biases, and family concerns.
- Delayed diagnosis of the femoral fracture occurred.
Conclusions:
- Behavioral changes in preverbal children, like refusal to walk, can signal serious pathology.
- Clinicians must avoid cognitive biases such as anchoring.
- Thorough whole-body assessment and incorporating family concerns improve diagnostic accuracy in pediatric trauma.
Objectives:
Diagnostic errors are multifactorial and tend to occur frequently in the emergency department. Pediatric emergency care presents unique challenges, particularly in the evaluation of trauma in preverbal infants who cannot adequately describe their symptoms. Herein, we present the case of an infant in whom irritability following minor head trauma was incorrectly diagnosed.
Case Presentation:
A 1-year-6-month-old boy presented to the emergency department with irritability following minor head trauma. The initial evaluation focused on the head trauma, and the child's irritability was attributed to an upper respiratory tract infection and the effect of the unfamiliar examination environment. The patient was discharged, but several hours later, he returned because of right thigh swelling, which revealed a femoral fracture. Root cause analysis using a fishbone diagram identified the contributing factors to the delayed diagnosis as the vague, clinical presentation of pediatric trauma, multiple cognitive biases, and the role of family concerns in clinical reasoning.
Conclusions:
In preverbal children, behavioral changes, such as a sudden refusal to walk, may indicate a serious pathology. Clinicians should avoid anchoring, perform a thorough, whole-body assessment, and take the family's concerns into consideration to ensure diagnostic accuracy in cases of pediatric trauma.
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