James O'Brien

Attempt review · why, not just what

James O'Brien · Acute Dyspnea After Arthroplasty

PGY-3 Internal Medicine · Resident

James was close; a few unpinned findings (and a distractor) explain where the reasoning slipped.

Why these went wrong

Each error traced back to the pin decisions that caused it

Diagnosis

Ranked Community-acquired pneumonia above Pulmonary embolism

BecausePinned the distractor “Hemoglobin” as if it were diagnostic, and never pinned “Systolic Blood Pressure” and “Clear chest on auscultation” — so the pre-test probability for Pulmonary embolism stayed low and a mimic outranked it.

Hemoglobin· DistractorSystolic Blood Pressure· Context factorClear chest on auscultation· Diagnostic clue

Pin the discriminating findings before committing the differential — they raise the pre-test probability that puts Pulmonary embolism on top.

Pin decisions vs. what mattered

The evidence behind the causal read

Pinned signalMissed signalFixated on distractor

Diagnostic clue

  • Pleuritic chest painPinned
  • Acute dyspneaPinned
  • Unilateral calf swellingPinned
  • Tachycardic, regular, no murmurPinned
  • Clear chest on auscultationMissed
  • Swollen, tender right calfPinned
  • D-dimerPinned
  • CT pulmonary angiography (CTPA)Pinned

Safety red flag

  • Heart RatePinned
  • Respiratory RatePinned
  • Oxygen SaturationPinned
  • Tachypnoeic and anxiousPinned
  • 12-lead ECG and continuous telemetry with repeat saturationsPinned

Context factor

  • Systolic Blood PressureMissed

Management modifier

  • Baseline CBC, creatinine and coagulation panelPinned
  • Platelet CountPinned
  • CreatininePinned

Distractor

  • TemperatureCorrectly ignored
  • HemoglobinFixated

Differential outcome

Submitted vs. expected ranking

DiagnosisExpectedLearnerOutcome
Pulmonary embolismWorking diagnosis#1#2Misranked
Acute coronary syndromeCan't-miss#2#2Correct
Aortic dissectionCan't-miss#4#4Correct
Community-acquired pneumoniaReasonable alternative#3#1Misranked
Spontaneous pneumothoraxReasonable alternative#5#5Correct

Pin recall, by intent

  • Diagnostic clue
    7/8
  • Safety red flag
    5/5
  • Context factor
    0/1
  • Management modifier
    3/3
  • Distractor
    1/2pinned