Maybe you are in the middle: Go up!

A 75-year-old woman with a diagnosis of breast cancer and slow growing pulmonary metastases went to the Emergency Department  (ED)  after a fall. The X-ray showed a bone fracture in the distal fibula. Three weeks later she went again to the ED referring weakness in her legs.

CLINICAL CASE: A month before the fall the patient was feeling a sensation of “ants” moving around her belly. At the second visit to the ED the doctor saw that the patient had her  bone fracture corrected and she was not able to walk. No sphincters disorders were present. At the first glance the problem of  ambulation was associated with bone fracture. A complete physical examination showed a loss of sensitivity  starting in the abdominal superior level. She has no strength to raise her legs. Tendon reflexes were absent.

A MNR showed the presence of an intramedullary metastases (T3-T4 level)

FINAL DIAGNOSIS: Spinal (intramedullary) metastases from breast cancer

COMMENT:

Imagine that you were the doctor attending the patient and your initial diagnosis was ” walking problem associated to the fibula fracture”, … What type or types of biases do you think could be involved in your wrong clinical reasoning?

[polldaddy poll=9300667]

ANSWER TO THE POLL: Number 5. All of these biases are present in this wrong clinical reasoning.