What diagnostic error did the physician make by attributing the chest pain and shortness of breath to gastro‑esophageal reflux and prescribing a proton‑pump inhibitor, thereby missing underlying congestive heart failure?

Premature Closure (Anchoring Bias)

The physician committed the error of premature closure—also known as anchoring bias—by rapidly forming a first impression that the patient had gastroesophageal reflux disease and failing to adequately consider life-threatening cardiac causes before prescribing a proton pump inhibitor. 1

Understanding the Diagnostic Error

The correct answer is B: First impression of the patient (which represents premature closure/anchoring bias). This cognitive error occurs when a clinician commits to a diagnosis too early in the diagnostic process and fails to adequately consider alternative, potentially life-threatening diagnoses. 1, 2

Chest pain and shortness of breath are cardinal symptoms that mandate cardiac evaluation first, regardless of how convincing a gastrointestinal presentation may appear. 1 The American College of Physicians emphasizes that any patient with new chest pain requires cardiac evaluation before attributing symptoms to GERD, as approximately 70% of chest pain cases are NOT caused by GERD. 1

Why This Represents Premature Closure

• The physician anchored on GERD as the diagnosis based on the symptom of "acidic chest discomfort" without ruling out cardiac causes first, which is a classic example of premature closure. 1, 2

• The combination of chest pain AND shortness of breath is a high-risk presentation that should immediately trigger consideration of congestive heart failure, acute coronary syndrome, and pulmonary embolism before considering benign gastrointestinal causes. 3, 1

• The American Heart Association explicitly recommends ruling out cardiac causes through appropriate evaluation (ECG, cardiac biomarkers, clinical assessment for heart failure) before attributing symptoms to GERD. 1

The Proper Diagnostic Approach

The stepwise approach for chest pain with dyspnea should prioritize life-threatening conditions:

1. Immediate cardiac evaluation including ECG and cardiac biomarkers to exclude acute coronary syndrome and assessment for heart failure (elevated jugular venous pressure, pulmonary rales, peripheral edema, S3 gallop). 3, 1

2. Consider pulmonary embolism if the patient has risk factors (immobility, recent surgery, malignancy) and perform appropriate risk stratification. 3

3. Only after excluding dangerous cardiac and pulmonary causes should a PPI trial be considered for presumed GERD. 3, 1

Critical Pitfalls to Avoid

• Never assume chest pain is benign or GERD-related without cardiac evaluation, even when the presentation seems to fit acid reflux. 1 The American College of Cardiology emphasizes this principle explicitly. 3

• GERD can cause shortness of breath through aspiration or vagal reflexes, but this diagnosis should only be entertained after excluding cardiac and pulmonary pathology. 4 Up to 75% of patients with GERD-related respiratory symptoms may lack classic heartburn, making the diagnosis challenging. 4

• The presence of both chest pain AND dyspnea significantly increases the likelihood of serious cardiopulmonary disease compared to chest pain alone. 3 This combination should trigger a broader differential diagnosis including CHF, pulmonary hypertension, and valvular disease. 3

Why the Other Options Are Incorrect

• Option A (Rapidly processing the patient) is not the primary error. While rushed decision-making can contribute to diagnostic errors, the fundamental problem here was cognitive—the physician formed an incorrect first impression and failed to consider alternative diagnoses, not that they worked too quickly. 2

• Option C (Enhanced patient communication) is not the error that occurred. Poor communication with patients about diagnostic uncertainty or treatment plans is a separate issue from the cognitive error of premature closure. 5

The Consequence of This Error

The patient's condition worsened over 2 days because CHF was left untreated. 3 Congestive heart failure requires specific therapies (diuretics, ACE inhibitors, beta-blockers) that were delayed by the misdiagnosis. 3 This delay in appropriate treatment directly resulted in clinical deterioration and an emergency department visit. 3

The key lesson: When evaluating chest pain with dyspnea, always exclude cardiac causes first through appropriate clinical assessment and testing before attributing symptoms to gastrointestinal disease. 3, 1