The red color. Chapter 2

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The red color. Chapter 2
Participants
The storyteller
 The patient (Mary)
Mary´s brother     
 An ophtalmologist
The storyteller

We saw in the previous chapter the case of Mary, a woman in her early fifties, with a diagnosis of cerebral hemorrhage in relation to an aneurysm. She was  saying to the doctor and to her family that she only could see a red color in her eyes.

The patient (Mary)

” Again, this red curtain, everything is red”. “I can´t see”

Mary´s brother

“I am really tired. The doctor said that he had checked everything and it is very clear the presence of visual hallucinations, but I am going to talk to the medical director to see if my sister can have an ophtalmic examination”.

An ophtalmologist

“Hello Mary. I am Dr. Claudio, I would like to explain to you what I would like to do. I am going to examine your eyes to see if you have this red curtain. Let me see. Ok, yes, it is true, you have a red curtain inside your eyes because they are full of blood. You will need a surgical intervention to clean your eyes. This situation happens sometimes after a cerebral hemorrhage like yours, and there is a name for it:  the Terson´s  syndrome”.

Final Diagnosis: Terson´s syndrome

Terson syndrome or Terson´s syndrome is the occurrence of a vitreous hemorrhage of the eye in association with subarachnoid hemorrhage, other intracranial hemorrhage and elevated intracranial pressure (1).

Bibliography

(1) George JS, Elston JS. Mysteri Case: Terson syndrome on CT. Neurology 2016; 87: e133-4.

CASE ANALYSIS
Basically, there were cognitive biases in the doctor´s reasoning, that we can summarize as:
1. Overconfidence bias:the doctor was sure that his idea about visual hallucinations was correct and he considered no indications for new tests or examination.
2. Confirmation bias: everything was orientated to confirm more that to reject the initial hypothesis
3. Premature closure: the doctor was sure that all the clinical possibilities were taking account in a differential, but he doesn´t, because in a wider list the inclusion of Terson syndrome was mandatory.
IMPROVEMENT AND RECOMMENDATIONS

-Check every small clinical detail

– It is important to elaborate an initial  wide differential diagnosis that you can reduce progressively

-Always paid attention to the considerations of the patient and the family

Author: Lorenzo Alonso, MD.

Foro Osler

 

 

 

 

 

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