Cognitive Bias in Inpatient Pediatrics

CASE 1

A 3-year-old male with no significant medical history presented to the emergency department (ED) with 11 days of a limp and 10 days of fever. His review of systems was otherwise positive for intermittent abdominal pain, increased loose stool, and a 3-pound weight loss. On examination, he had no point tenderness or swelling or erythema over either extremity; results of his neurologic examination were normal. The patient’s laboratory work was significant for a white blood cell count of 18.9 × 10³/μL, hemoglobin of 10.8 g/dL, erythrocyte sedimentation rate of 65 mm/h, and C-reactive protein of 51.5 mg/L. Given the patient’s fever, limp, and elevated inflammatory markers, the inpatient team began an evaluation for osteomyelitis. A bone scan was positive in the area of the left lateral femoral condyle, and a follow-up MRI revealed inflammatory changes in the medial femoral metaphysis and epiphysis. He was diagnosed with osteomyelitis and was discharged from the hospital on intravenous antibiotics. Two weeks later, the patient presented with worsening abdominal pain, loose stool, and continued elevation in his inflammatory markers. A colonoscopy was performed and revealed evidence of Crohn’s disease. On review, the inflammatory changes seen previously on the MRI were consistent with chronic recurrent multifocal …