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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of euvolemic hyponatremia

  • List common etiologies of euvolemic hyponatremia

  • Identify the goals of therapy for euvolemic hyponatremia

  • Develop an appropriate treatment and monitoring plan for euvolemic hyponatremia on the basis of individual patient characteristics

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PATIENT PRESENTATION

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Chief Complaint

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Fall (per family)

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History of Present Illness

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Albert Buterol 89-year-old Caucasian man fell head-first down 5–6 concrete steps. His fall was witnessed by his wife and he had no previous history of falls. He initially lost consciousness for about 5 minutes, after which he was confused. He was taken to a local rural hospital where a CT scan demonstrated an intracranial hemorrhage, chest x-ray showed pneumonia, and he became unresponsive. He was then transferred to a university hospital, where his intracranial hemorrhage was managed with IV nicardipine, mechanical ventilation, antibiotics for suspected pneumonia, and hypertonic saline for hyponatremia. On admission, the patient had no evidence of volume depletion or excess on physical examination. The serum sodium on admission was 119 mEq/L (119 mmol/L) and increased to 129 mEq/L (129 mmol/L) within the first 24 hours.

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Allergies

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Antihistamines: Unspecified

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Sulfa: Unspecified

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Tramadol: Unspecified

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Amitriptyline: Unspecified

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Past Medical History

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MI, postpercutaneous coronary intervention (PCI)

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HTN

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Pacemaker for bradycardia

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Frequent UTI (enlarged prostate)

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Social History

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Quit smoking 10 years ago

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Denies alcohol and illicit drug use

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Medications Prior to Admission

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HCTZ 50 mg PO daily

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Celecoxib 200 mg PO daily

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Finasteride 5 mg PO daily

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Pantoprazole 40 mg PO daily

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Cotrimoxazole PO twice daily

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Lorazepam 1 mg PO every 8 h as needed for anxiety

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Latanoprost eyedrops, 1 drop in both eyes at bedtime

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Inpatient Medications

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Pantoprazole 40 mg IV daily

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Piperacillin/tazobactam 3.375 mg IV every 6 h

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Levofloxacin 750 mg IV q 24 h

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Vancomycin 1 g IV q 24 h

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3% saline initiated IV at 15 mL/h

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Codeine 15–30 mg per NG tube every 8 h as needed for cough

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Metoclopramide 10 mg IV every 6 h as needed for nausea

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Nicardipine IV infusion to keep systolic BP <160 mm Hg

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Potassium chloride 40 mEq (40 mmol) IV × 1

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Review of Systems

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Unattainable as the patient is unresponsive

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Physical Examination

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General
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Frail with some ...

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