Case 3

Setting: ED

“My husband has been really confused.”

BP:112/76 mm Hg; P: 98 beats/minute; T: 99°F; R: 22 breaths/minute

HPI

A 58-year-old man with lung cancer diagnosed several weeks ago is admitted to the ED. He has been undergoing a staging evaluation and has not started therapy. He is brought in by his wife because he has been increasingly confused over the past 2 days.

PMHX

Tobacco smoking for 30 years, quit 5 years ago
Hypertension

Medications

Amlodipine

Order naloxone, dextrose, and thiamine first and then do Physical Examination➜ Go ahead with Physical Examination➜ Take detailed history➜

Physical Examination

General

visibly agitated and confused

Neurological

lethargic, confused, only able to state his name; examination incomplete secondary to inability to follow commands

Cardiovascular

normal

Abdomen

normal

Initial Orders

sodium 112 mEq/L; BUN 8 g/dL; creatinine 0.7 mg/dL
Oximeter: 97% on room air
Calcium: 9.2 mg/dL (normal)
Head CT: no metastases

Once you add up Lung cancer and hyponatremia, you know what to do.

X- Was written in really poor handwriting
Conivaptan IV
Repeat chemistry
Urine sodium, urine osmolarity
Uric acid level
Transfer patient to ICU

Reports after some time

Urine sodium 64 mEq/L (high)
Urine osmolarity 480 mOsm/kg

Your student came to ask you what **X** is.

What will you tell her?

3% hypertonic saline➜ Normal Saline➜ Furosemide➜ Normal Saline + Furosemide➜

No significant history is obtained and the patient family is too stressed to co-operate. What’s the next step?

order naloxone, dextrose, and thiamine first and then do Physical Examination➜ Go ahead with Physical Examination➜

Explain Type

Your senior comes and asks you.

Explain

What would happen if you had given the patient Normal Saline?
What if you gave NS + Furosemide?

Remember

The sodium content of NS is 154 mEq/L, while this patient has a sodium level of 112 or 114 mEq/L. Urine osmolarity- 480 mOsm/kg, as seen in the reports before.

Too rapid increase in sodium. I have written my explanation on the sheet provided. Name it NS➜ Too slow increase in sodium. I have written my explanation on the sheet provided. Name it NS➜ No change in sodium. I have written my explanation on the sheet provided. Name it NS➜ Further Decrease in sodium. I have written my explanation on the sheet provided. Name it NS➜

Explain Type

Your senior comes and tells you that you are wrong and that they have started the patient on 3% hypertonic saline.

Explain

What would happen if you had given the patient Normal Saline?
What if you gave NS + Furosemide?

Remember

The sodium content of NS is 154 mEq/L, while this patient has a sodium level of 112 or 114 mEq/L. Urine osmolarity- 480 mOsm/kg, as seen in the reports before.

After 4 hours, the serum sodium level rises to 117 mEq/L. Symptoms start to improve and the patient is less confused.
You feel that the speed of recovery is slow and wish to increase the speed of sodium recovery so that the patient recovers quickly. Your senior tells you that it is a very dangerous idea and that you shouldn’t step into the ICU carrying such thoughts!!. What complication makes this idea dangerous?

Monocular blindness➜ Central pontine demyelinization➜ Cerebral edema➜ Transverse myelitis➜

Hope you enjoyed the case. Reference- SIADH, Internal Medicine- Correlations and Clinical Scenarios Good Job Doctor!!

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