Friday, April 22, 2011

Intern Report Case Presentation 3.9


Case Presentation by Dr. Deshon Moore


A 67-year-old man with a significant medical history of COPD, CAD requiring many interventions, CHF, sustained ventricular tachycardia, and diverticulosis came to the emergency department with a 2-week history of generalized abdominal pain non positional and not related to food. He also complained of general weakness over the past several months.  No c/o weight loss, no changes in urination volume.
Physical exam showed no pertinent findings. 

Initial laboratory values were drawn and showed a serum sodium concentration of 117 mEq/L (normal 135-145 mEq/L). The patient's medical records indicated that almost 3 months earlier his serum sodium concentration was 134 mEq/L. Three weeks after that visit, his serum sodium concentration was 126 mEq/L. 

On presentation the patient stated he was on amiodarone, Aspirin, Metoprolol, Nitroglycerin, lisinopril, furosemide, spironolactone, and simvastatin. The majority of his meds were started 3 mos ago.

Further Labs: 
Serum osmolality 264 mOsm/kg, 
U osm-730 mOsm/kg 
Glu 120 mg/dl, 
BUN 11 mg/dl, 
Cr 1.0 mg/dl, 
K- 4.4 mEq/L

Complete blood count and thyroid-stimulating hormone and thyroxine levels were normal; corticotropin stimulation test result was negative; chest radiograph showed no infiltrates or masses; and thoracic CT revealed no evidence of malignancy. An abdominal CT scan was normal. 

Despite fluid restriction (< 1000 ml/day), serum sodium concentrations were 118-120 mEq/L over the next 2 days after admission.

Amiodarone was discontinued based on a publications suggesting that this drug can cause SIADH-induced hyponatremia. The patient's serum sodium concentration began to rise within 3 days of discontinuation and was 129 mEq/L at discharge the next day. At an internal medicine follow-up visit the patient's serum sodium concentration was within normal limits at 136 mEq/L. Symptoms of abdominal pain and general weakness improved as serum sodium levels increased. 
Questions:

An 80-year-old woman who presented to the emergency department with weakness and dizziness had labs reveal a serum osmolality of 260 mOsm/kg, serum sodium of 125 mEq/L (normal 135–154 mEq/L), Urine sodium level of 50 mEq/L (normal, 0–300 mEq/L) and urine osmolality of 200 mOsm/kg. She takes furosemide for peripheral edema. Her PCP prescribed HCTZ for htn 1 week ago. The patient denies fevers, chills, nausea, or vomiting. She claims to be more thirsty than usual and has been drinking apple juice in response. BP is 100/60 mm Hg lying down and 84/40 mm Hg sitting. She weighs 60 kg.

1. Which of the following is this patient’s most likely diagnosis?
(A) Adrenal insufficiency
(B) Furosemide-induced hyponatremia
(C) Hydrochlorothiazide-induced hyponatremia
(D) Syndrome of inappropriate antidiuretic hormone
(SIADH)
(E) Thyroid disease

2. How should this patient be managed?
(A) Give intravenous (IV) normal saline (0.9%) at
125 mL/hr
(B) Give IV 5% dextrose in half-strength normal
saline at 50 mL/hr
(C) Restrict free water intake orally
(D) Provide salt tablets orally

 3. 50-year-old man admitted to the CCU with a MI has a sodium level of 124 mEq/L. There are no other laboratory abnormalities; however, the sample is lipemic. The patient is resting  comfortably and denies any symptoms. Which of the following is most likely to establish the  diagnosis?

(A) Serum osmolality
(B) Serum uric acid
(C) Urine osmolality
(D) Urine sodium

4.  You have a type 2 diabetic with ESRD on HD who presents with weakness. He missed dialysis and ran out of his long-acting insulin 2 days ago. No other complaints. Physical Examination is unremarkable, including a normal neurologic examination. CXR negative. 12 lead ECG-NSR w no T wave abnormality

Labs: Sodium-125 mEq/L, K-5.2 mEq/L, Serum Glu- 700 mg/dL, Serum Osm 310 mOsm/kg
Which of the following is the most appropriate
next step in this patient’s management?

(A) Immediate hemodialysis
(B) Initiate IV short-acting insulin therapy
(C) Restart subcutaneous insulin therapy for dosing
at home
(D) Restrict free water to correct hyponatremia

5. How many oz of water do you drink a day?

(A)  <16 oz/ day
(B)  16-32 oz/day
(C)  48 oz/day
(D)  >54 oz/day
(E)  Only coffee

Please submit your answers as a comment. Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

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