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Jan Andre Montemayor, M.D.
March 16, 2015
Objectives
Cite the clinical coarse of a patient with
hyponatremia
M.M. 63F
Hypertensive (2014)
Non smoker
Non alcoholic beverage drinker
Previously admitted due to weakness, d/c stable
Chief Complaint
Body weakness
Vomiting x2 PIF
Took unrecalled medications
No relief
DOA
Persistence of vomiting
Associated with weakness described as loss of
balance
At the E.R.
Wheelchair borne, conversant weak looking
Stable vital signs BP 140/80 PR 72 RR 20 36.3.
Dry lips, -NVE, CBS, NRRR, no edema, pulses good
CBC, Baseline CBG 97, Na 120, K 4.30, and Crea 74
Initial IMP: Acute gastroenteritis with signs of
dehydration with a consideration of electrolyte
imbalance probably secondary to poor oral intake
Repeat Na 108
No clinical signs improvement
Referred to Internal medicine for comanagement
Further Review of history, patient was noted
fluid intake at home (3L?)
Tx
Given furosemide 20mg IV
Suggest to incorporate 30%NaCl 20mL in current
IVF
Fluid restriction 1L
Na 115
referred to a nephrologist
given tolvaptan tablet
, per
Discussion
Hyponatremia
Serum sodium < 135 mmol/L
Pseudohyponatremia: Correction
factors
Hyperglycemia:
Corrected serum Na+ =
Measured Na +[2.4 ((RBS (mg/dl) 100)/100)]
cal practice guideline on diagnosis and treatment of hyponatremia . Journal of Endocrinology 2014;170
Patients baseline
characteristics:
There is no pseudohyponatremia:
CBG = 99mg%
Physical examination: No volume depletion
(BP = 140/90; HR = 72/min), good skin turgor
Establishment of
chronicity
3 days prior to consult, patient already
presented with vomiting along with generalized
weakness described as loss of balance.
Chronic hyponatremia:
documented to exist for at least 48 h.
Moderate" hyponatremia:
Serum concentration between 125 and 129
mmol/L
Profound" hyponatremia:
Serum concentration less than 125 mmol/L
Definition based on
symptoms
Moderately symptomatic hyponatremia
biochemical degree of hyponatremia in the presence of
moderately severe symptoms of hyponatremia
Nausea without vomiting
Confusion
Headache
Chronic hyponatremia
(Admitting serum
Na = 120mmol/L)
The recommendation:
cal practice guideline on diagnosis and treatment of hyponatremia . Journal of Endocrinology 2014;170
cal practice guideline on diagnosis and treatment of hyponatremia . Journal of Endocrinology 2014;170
Management:
Our patient was initially given plain NSS and
Furosemide
Management:
rogue-Madias formula:
hange in Na+ = [Na(infusate) Na+ (patient
(Total body water + 1)
Change in Na+ =
(154-104)/ ( 27.5 + 1)
= 1.9
1 L of NSS is expected to increase the serum [Na+] by
1.9
To increase the serum [Na+] by 10-12 mmol in 24 hours,
we need to give
5.2L - 6.3L of NSS
Hyponatremia
Yes
No
Urine
osmolality
> 100 mosm/kg
100
mosm/kg
Urine Na
concentration
30 mmol/L
> 30 mmol/L
Diuretics or
kidney disease
Yes
No
Robert Schrier. Body Water Homeostasis: Clinical Disorders of Urinary Dilution and Concentration. J
Am Soc Nephrol 2006;17: 18201832
In overtly symptomatic
hyponatremia:
cal practice guideline on diagnosis and treatment of hyponatremia . Journal of Endocrinology 2014;170