A 58 year-old Hispanic woman presented to an outside hospital with a one-day history of right upper quadrant abdominal pain. The pain was 8/10 in severity, sharp in nature, and radiated to her lower abdomen. Her past medical history was significant for alcoholic cirrhosis for which she underwent liver transplantation 10 years prior. The patient underwent abdominal CT, which demonstrated portal vein thrombosis. She was then transferred to our hospital for further management. Review of systems on arrival was notable for a longstanding cough with blood-tinged sputum, dyspnea at rest, and chronic voice hoarseness. Physical exam was significant for elevated jugular venous pressure, a rumbling diastolic murmur heard best at the cardiac apex, mild bibasilar rales, right upper quadrant tenderness to palpation without rebound or guarding, and bilateral lower extremity edema. Serum laboratory studies were unremarkable. Chest radiograph demonstrated cardiomegaly and mild central vascular congestion. Transthoracic echocardiogram was subsequently obtained, which demonstrated a rheumatic-appearing mitral valve with an area of 0.75 cm2 suggestive of severe stenosis with associated severe pulmonary hypertension based on a pulmonary artery systolic pressure of 108 mmHg. During hospitalization, patient was managed with careful diuresis, initiated on therapeutic anticoagulation for portal vein thrombosis, and referred to cardiothoracic surgery for mitral valve replacement evaluation.
Our patient presented to an outside facility with right upper quadrant abdominal pain, which was attributed to acute portal vein thrombosis. On arrival to our facility, however, review of systems suggested concurrent congestive heart failure. This was supported by physical exam, which demonstrated elevated jugular venous pressure, bibasilar rales, a rumbling diastolic murmur, and hoarseness (Cardiovocal or Ortner’s syndrome). These signs and symptoms warranted further investigation with an echocardiogram, which led to the diagnosis of severe mitral valve stenosis. If the work-up would have halted upon discovery of the portal vein thrombosis, the patient’s valvular disease would have gone undiagnosed. It can be argued that had a comprehensive assessment taken place earlier, earlier initiation of treatment and/or intervention may have prevented the complications associated with severe valvular disease (i.e. pulmonary hypertension).
Our case illustrates the importance of avoiding anchoring bias during medical decision-making, which has been identified as the most common cognitive bias by internal medicine residents. Another essential point of this case is to highlight the importance of taking a thorough history and performing a comprehensive assessment in patients to help decrease diagnostic errors and avoid missing critical diagnoses.
To cite this abstract:Cigarroa J IV, Fiazuddin F, Kornsawad K. To Anchor or Not to Anchor? – a Case of Thrombosis, Hoarseness, and Orthopnea. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 473. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/to-anchor-or-not-to-anchor-a-case-of-thrombosis-hoarseness-and-orthopnea/. Accessed May 22, 2019.