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Sodium, porphyria, and medical malpractice

After multiple physician appointments, an ER doctor made the right diagnosis

It’s amazing how the different systems of our body generally work together seamlessly. When something goes wrong with one of the systems, though, it can cause problems that aren’t immediately obvious.

That’s why it’s important to patient safety that primary care and emergency physicians follow the differential diagnosis process with every patient every time. The differential diagnosis process is taught to medical students in their first year of medical school and is repeated throughout their training.

Here’s how it works.

Patients don’t come with instruction manuals. Patients seek physician care when something’s wrong and they describe the problem or what they’re feeling. It’s up to the doctor to make a list of every potential condition that could explain the clinical signs and symptoms. That’s called the differential diagnosis list. Then, by a thorough patient interview or history, physical exam, lab work, and/or diagnostic radiology imaging, the standard of care requires the doctor to work through the differential diagnosis list one at a time, starting with the most dangerous condition.

As you can imagine, this takes time. And the current health system of administrators, insurance companies, and bean counters that expect short, fast patient visits isn’t conducive to this type of individualized attention to each patient, but that’s what’s required by the standard of care.

A woman in her late 20s experienced the good and the bad of differential diagnosis at different facilities where she sought treatment for the same disorder. Let’s start with the bad.

The patient went to a hospital for evaluation after having a week of repeated episodes of severe abdominal pain that would come and go. Her lab work was significant for a critically low serum sodium level. This dangerous condition is called hyponatremia and if it’s not carefully treated, it can lead to a permanent brain injury. She was treated appropriately with intravenous (IV) fluids and the rest of her exam was unremarkable, so she was discharged with painkillers.

Less than a week later, the symptoms were back with a vengeance, so she went to a different hospital. There, she was again found to be hyponatremic. She was admitted for treatment with IV fluids before being discharged.

Fast-forward two weeks, and she’s back at a third hospital with the same symptoms, where she is once again found to have a low sodium level, treated with IV fluids, and discharged. The next day, her primary care provider sent her by ambulance to the hospital emergency room because she was holding her abdomen and crying out in pain. On exam, all four quadrants of her abdomen were tender.

Finally, an emergency room physician looked at this patient as an individual and took the time to do some research and ask the patient some pointed questions. This led the doctor to add a hereditary (inherited) condition called acute intermittent porphyria (AIP) to the differential diagnosis list.

The Mayo Clinic describes porphyria as a group of conditions caused by excess porphyrin, which are natural chemicals found in the body that are related to hemoglobin and blood function. When the levels of porphyrin get too high, they can cause severe problems, including hyponatremia and severe abdominal pain.

When the emergency physician followed the differential diagnosis process, she ordered urine lab work, which confirmed the diagnosis, in addition to IV saline to address the recurrent hyponatremia. As a result, in addition to handling the flareups with a Band-Aid approach, the ER doctor determined the cause of the problem and referred her to a hematologist, a blood specialist, for further workup.

If you’ve been seriously injured because of undiagnosed or poorly treated hyponatremia or acute intermittent porphyria in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for free consultation about your potential case.


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