Blaser Simone, Schaye Verity, Hwang John, Cocks Patrick, Kudlowitz David
NYU Internal Medicine Residency, NYU Langone Health, New York, NY, USA.
Division of General Internal Medicine & Clinical Innovation, NYU Langone Health, New York, NY, USA.
Diagnosis (Berl). 2021 Aug 5;9(1):133-139. doi: 10.1515/dx-2020-0149.
Our discussant's thoughtful consideration of the patient's case allows for review of three maxims of medicine: Occam's razor (the simplest diagnosis is the most likely to be correct), Hickam's dictum (multiple disease entities are more likely than one), and Crabtree's bludgeon (the tendency to make data fit to an explanation we hold dear).
A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team's working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient's renal failure was more likely a result of a chronic, unrelated process.
It is tempting to bludgeon diagnostic possibilities into Occam's razor. Presumption that a patient's signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam's dictum than to Occam's razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.
我们的讨论者对该患者病例的深入思考促使我们回顾医学的三条准则：奥卡姆剃刀原理（最简单的诊断最有可能正确）、希卡姆格言（多种疾病并存比单一疾病更常见）以及克拉布特里的重击（使数据符合我们珍视的解释的倾向）。
一名66岁有高血压病史的女性从几内亚抵达美国一天后因每日慢性呕吐、非故意体重减轻和进行性肩部疼痛前来我院就诊。她的实验室检查结果显示肾衰竭、肾病范围蛋白尿和正细胞性贫血，而她的肩部X线显示右侧锁骨外侧骨质吸收。多发性骨髓瘤成为团队的初步诊断；然而，随后的肩部活检结果与滤泡性甲状腺癌一致。影像学检查提示患者的肾衰竭更可能是由一个慢性的、不相关的过程导致的。
人们很容易将诊断可能性强行纳入奥卡姆剃刀原理。假设患者的体征和症状由单一疾病过程引起通常会使我们在认知上具有优势。然而，非典型表现、多种疾病过程以及特殊人群往往更符合希卡姆格言而非奥卡姆剃刀原理。诊断辅助手段包括进行元认知清单检查、运用分析性思维以及承认这些公理的不完美之处。
