Ilaiwy Amro, Thompson Novelette Elvia, Ameen Waheed Ahmed
Internal Medicine, University of Miami Miller School of Medicine at Holy Cross Hospital, Fort Lauderdale, Florida, USA.
BMJ Case Rep. 2018 Sep 28;2018:bcr-2018-226458. doi: 10.1136/bcr-2018-226458.
Hyponatremia is a common electrolyte disorder, with prevalence as high as 20% in inpatient settings. It is classified based on volume status, urine sodium and osmolality results. While this approach might help narrow down the differential diagnoses, it can leave other diagnoses unentertained. In this case, we report recurrent and refractory hyponatremia secondary to hypocortisolism due to non-functioning pituitary macroadenoma. Interestingly, urine studies mimicked syndrome of inappropriate antidiuresis, but exclusively responded to hydrocortisone replacement. Hospital course was also complicated by hyponatremia-induced rhabdomyolysis, which is a rare complication of severe hyponatremia. We also discuss the role of anchoring heuristics and how they influence the physician's decision leading to possible diagnostic errors. One way to minimise the effect of anchoring bias on physicians is their cognitive awareness of such bias. In addition, discussing complicated cases with all members of medical team can highlight the clinician's thought processes, share uncertainty and help broaden differential diagnoses.
低钠血症是一种常见的电解质紊乱，在住院患者中的患病率高达20%。它根据容量状态、尿钠和渗透压结果进行分类。虽然这种方法可能有助于缩小鉴别诊断范围，但可能会遗漏其他诊断。在此病例中，我们报告了因无功能垂体大腺瘤导致皮质醇减少继发的复发性难治性低钠血症。有趣的是，尿液检查结果类似抗利尿激素分泌失调综合征，但仅对氢化可的松替代治疗有反应。住院过程还因低钠血症诱发的横纹肌溶解而复杂化，这是严重低钠血症的一种罕见并发症。我们还讨论了锚定启发法的作用以及它们如何影响医生的决策并导致可能的诊断错误。减少锚定偏差对医生影响的一种方法是他们对此类偏差的认知意识。此外，与医疗团队的所有成员讨论复杂病例可以突出临床医生的思维过程，分享不确定性并有助于拓宽鉴别诊断范围。
