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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of hypovolemic hyponatremia

  • Identify the goals of therapy for hypovolemic hyponatremia

  • Develop an appropriate treatment and monitoring plan for fluid replacement based on individual patient characteristics

  • Select an appropriate resuscitation fluid

  • Recognize what type of patient may be predisposed to fluid overload

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PATIENT PRESENTATION

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Chief Complaint

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Diarrhea and altered mental status as per neighbor

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History of Present Illness

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Frank Secretion is a 78-year-old Caucasian man who was found by a neighbor wandering outside his residence with his pants saturated with urine and watery stool. The patient appeared intoxicated but he was oriented to person. He was found to have been falling down repeatedly while walking. The patient lives alone and is a widower. His daughter last spoke to him 4 days ago. The patient was unwillingly taken to a university hospital, where he was seen in the emergency department (ED) and admitted to the ICU for further management. In the ED, the following laboratory results were noted: sodium 121 mEq/L (121 mmol/L), potassium 3.0 mEq/L (3.0 mmol/L), chloride 88 mEq/L (88 mmol/L), BUN 47 mg/dL (16.8 mmol/L), creatinine 2.5 mg/dL (221 μmol/L), and ethanol level 150 mg/dL (32.5 mmol/L).

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Past Medical History

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HTN for 20 years

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Alcoholism (18 beers/d)

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Leg wound (new)

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Family History

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Father died of MI in his 50s. Mother died at age 92 from Alzheimer's disease. He has one daughter (46 years), who is healthy.

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Social History

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Retired carpenter. Completed high school. Married for 50 years. Widower for 1 year. Lives alone.

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Tobacco/Alcohol/Substance Use

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Long history of alcoholism; (−) tobacco or illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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No known allergies

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Medications (Prior to Admit)

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HCTZ 50 mg PO daily

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Simvastatin 40 mg PO daily

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Medications (ICU list)

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Normal saline

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IV potassium chloride 40 mEq (40 mmol) IV × 1

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Piperacillin/tazobactam 2.25 g IV q 6 h

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Lorazepam 1 mg IV/PO q 1 h PRN (agitation or tremor) per CIWA alcohol-withdrawal protocol

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Folic acid 1 mg PO daily

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Thiamine 100 mg PO daily

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Multivitamin 1 tablet PO daily

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Enoxaparin 40 mg SC q 24 h

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Review of Systems

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Unobtainable. Patient is extremely drowsy and disoriented.

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Physical Examination (in ED)

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General
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Unshaven unkempt elderly man with clothing saturated with urine and stool. He is oriented to person ...

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