General Data Name of Patient: M.C.B. Age/Sex: 96 yrs.old / Female Address: Meycauyan Bulacan ...

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General Data

Name of Patient: M.C.B. Age/Sex: 96 yrs.old / Female Address: Meycauyan Bulacan Civil Status: Married Nationality: Filipino Occupation: none Religion: Catholic

Chief Complaint

Dizziness

HPI Hypertensive (2000)

Highest: 160/100 mmHg; Usual 120/80 mmHg

Losartan potassium + hydrochlorthiazide (combizar) 50mg OD

Interval period: (+) chest heaviness, relieved by intake of meloxicam 15mg prn

8 days PTA (+) dizziness, fell (-) loss of consciousness

HPI 7 days PTA

(+) pain, swelling, bruises right shoulder and arm

POC, X ray right shoulder was done A> Oblique fracture displaced head of the

proximal humerus right M> cast was applied, celecoxib 500mg/tab

1 tab BID then prn; TCB: 2 weeks after 6 days PTA

(+) bruises chest, back (+) pain at the right shoulder area

temporary relived by celecoxib (+) gradual loss of appetite, (+) weakness,

(+) bed ridden

HPI 3 days PTA

(+) yellow discoloration of the skin (-) abdominal pain, (-) vomiting, (+) tea colored urine; (-) changes in

stool characteristics, (-) hematochezia, (-) hematemesis

2 day PTA Agitated, removed the bandage of the cast (+) pain at the right shoulder POC: work up and cast placement done CBC: anemia(hgb 62, hct 0.19); Urinalysis: pyuria

(28-30/hpf) and bacteuria (3+) PT and aPTT: elevated ECG: marked sinus bradycardia

Due to lack of facilities, patient opted to transfer to our institution, hence admission

Review of Systems

No nausea, vomiting No tinnitus, ear discharge No epistaxis, nasal discharge No gum bleeding, (-) hyperemic pharyngeal wall No hematemesis, no hematochezia No heat or cold intolerance, tremors, polydipsia,

polyuria (+) urgency, frequency, no flank pain,

hypogastric pain No limitation of Range of motion, Myalgia No seizures, paresthesia, headache

Past Medical History

Enucleation Right eye : Glaucoma (1980’s) Hypertensive Urgency (2007) MCU

BP: 160/100 mmHg (highest) Usual 120/80mmHg (+) epistaxis (-) chest pain, headache, nape pain or focal

deficit Nasal packing was done.

Fracture of the right proximal leg (2008) Cataract surgery left eye (2009) (-) DM, allergies, Asthma, Thyroid disease

Personal and Social History

Denies smoking, denies ethanol beverage drinking, denies illicit drug use

Mixed food diet No regular exercise

Family History

(+) DM type 2 - son (+) Bell’s palsy -Son (+) Heart attack HPN – eldest son (-) Cancer, (-) allergies, (-) asthma (-)

blood dyscaria (-) thyroid disease

Physical ExaminationConscious, lethargic, incoherent,

wheelchair borne, in respiratory distressBP:140/80mmHg CR 60bpm/regular

RR 29cpm/regular T 36.7oCHt 157.48 cm Wt: 70kg BMI: 29Warm moist skin, (+) hematoma(bluish-

black patches) over the upper extremities, chest and back; (+) pustules scattered at the neck and face; (+) jaundice

Enucleated right eye; Left eye: pale palpebral conjunctivae, icteric sclera, pupil 3-4mm ERTL

No tragal tenderness, midline septum, no nasoaural discharge

Moist buccal mucosa, uvula midline, tonsils not enlarged, non-hyperemic posterior pharyngeal wall

Supple neck, neck veins not distended, trachea midline, no palpable cervical lymphadenopathies, no thyromegaly

Physical Examination

I:Symmetric chest expansion, no use of accessory muscles, (-) intercostal retractionsP: Equal tactile and vocal fremiti on both lungsP: Resonant on both lung fields upon percussionA: Clear breath sounds on both lung fields(-) crackles

Physical Examination

JVP: 3.5 cm at 30 degrees Carotid pulse: rapid upstroke, gradual downstroke, Adynamic precordium, apex beat at 6th LICS AAL sustained, localized, no thrills, lifts, heaves, S1>S2 at the apex, S2>S1 on the base, no murmurs

Physical ExaminationAbdomen:I: flabby abdomen (-) visible pulsation, (-) distensionA: Normoactive bowel sounds, (-) bruit P: Tympanitic on all quadrants, Traube’s space not obliteratedP: No masses, (+) CVA tenderness, Liver span 8cm, smooth liver edge

Musculoskeletal/Extremities:Right shoulder:(+) cast/ splint, bruises, edema, limitation of motion

Rest of the extremities:No swelling, no cyanosis, clubbing, edema

Pulses are full and equal

Neurologic Examination

Conscious, lethargic, not oriented to time and place

GCS 10 (E3V2M5)Cranial Nerves:

◦ II – pupils 3mm constricting to 2mm ERTL, no ptosis, (+) ROR, III, IV, VI – EOMs full and equal , V – Intact motor, (+) corneal reflex, VII – No facial asymmetry, can raise eyebrows, can frown, smile, and puff out both cheeks, VIII – slight hearing deficit, IX, X – Uvula midline ,XI – Can raise shoulder, XII – Tongue midline on protrusion

Not assessed due to patients uncooperativeness:Cerebellar ,MMT, Sensory

DTR’s +2 on all extremities except the right upper extremities

No signs of meningeal irritation

No Babinski, no pathological reflexes

Assessment on admission

1. ASHD, CAD Sinus bradycardia, left ventricular hypertrophy, t/c sinus node disease, not in failure, Class III-C

2. Sepsis, prob 2nd to UTI3. Hemolytic anemia, prob 2nd to sepsis4. Multiple fractures, R humerus, pelvis5. t/c electrolyte imbalance prob 2nd to

diuretic use (thiazide)

Plans

General Neutropenic Diet IVF: PNSS IL to run at 24 gtts/min Monitor VS q1 and record Monitor I&O q shift and record

Plans

Diagnostic CBC with platelet count, retic count; PT, aPTT;

ABO and rH Peripheral smear Creatinine, LDH Na, K, iCa, iPO, Mg Xray of the right humerus 12 lead ECG Plasma osmolality Urine culture and sensitivity 2 D echo once stable

Plans

Therapeutic Atorvastatin 80mg/tab 1 tab ODHS Enalapril 5mg/tab 1 tab OD Trimetazidine 35mg/tab 1 tab BID Tramadol ₊ Paracetamol tab 1 tab q8

prn for pain For blood transfusion of 2 U of pRBC Coaptation splint, right arm Calcium gluconate 10%, 10ml

Laboratory ResultsDate Time Na Urine

NaK Urine

KiCa Mg iPO

49/30/2010

9:00pm 111.44

4.41

1.09

1.75

10/1/2010

7:15am 115 50 4.38

27.31

5:40pm 118 3.50

2.21

10/2/2010

5:15am 120 3.36

1:50pm 126.67

3.99

9:51pm 126.32

3.92

10/3/2010

11:00am 126 4.28

9:15pm 128.69 3.63

Creatinine BUN Plasma Osmolality

Urine Osmolality

9/30/2010

0.91

10/1/2010

34.57 272 374

10/2/2010

0.87

Coombs Test Direct - Negative Indirect - Negative Autocontrol - Negative

Ref range Unit 9/30 10/6

Hgb 120-170 g/L 82 99

HCT 0.37-0.54 0.23 0.29

Platelet 150-450 X10^9/L 216 222

WBC 4.5-10.0 X10^9/L 29 11.40

Differential Count

Neutrophils 0.50-0.70 0.83 0.90 0.75

-Metamyelocytes

-Bands 0.00-0.05 0.04

-Segmented 0.50-0.70 0.86

Lymphocytes 0.20-0.40 0.10 0.23

Monocytes 0.00-0.07 0.01

Eosinophils 0.00-0.05 0.01

Basophils 0.00-0.01

retics 245

RPI 2.39

Nucleated rbc 03n/100wbc

Laboratories

September 30, 2010 SGPT : 41.21 Total Bilirubin 7.22

Direct Bilirubin 1.24 Indirect Bilirubin 5.98

LDH: 1,250

Urinalysis Date Findings

10/1/10 Color: reddish Consistency: sl. Turbid pH 6.5 spgr 1.015 alb +++ sugar (-) RBC 3-6/hpf pus cell 10-15/hpf bacteria ++ a. urates ++

10/6/10 Color: yellow, turbid, 5.0, 1.020, hya 03/cvrslp, granular over 50/cvrslp, sugar++ alb++, rbc 0-3hlf, pus cell 15-25/hpf, bact4+, MT2+, AU 3+

9/31 10/1Trop I 0.17

CKMM 3101.91

CKMB 50.09

CK total 3132

10/1

PT 12.6

aPTT 36.8

Chest XrayDate

Findings

10/1/10 Cardiomegay, left ventricular, atheromatous aorta, mild pulmonary congestion, incidentally, marked osteopenia of the visualized bony structures

10/3/10 Slight progression of the previously noted mild pulmonary congestion. NGT noted. Previously noted comminuted fractures of the right proximal humerus, the rest of the findings : no significant interval change

V. ECGDate

Findings

9/31/10 Sinus bradycardia, non specific ST-T wave changes

10/1/10 Sinus rhythm, 1sr degree AV block, note: compared to EC tracing done 9/30/10; 8:pm severe bradycardia is now absent

Laboratory ResultsDate Na Urine

NaK Urine K iCa Mg iPO4

9/30/2010 111.44 4.41 1.09 1.75

10/1/2010 118 3.50 2.21

115 50 4.38 27.31

10/2/2010 120 3.36

126.67 3.99

126.32 3.92

10/3/2010 128.69 4.28

Creatinine BUN Plasma Osmolality

Urine Osmolality

9/30/2010

0.91

10/1/2010

34.57 272 374

10/2/2010

0.87

Hyponatremia

plasma Na+ concentration <135 mmol/L

Water shifts into cells causing cerebral edema

125 mEq/L – nausea and malaise 120 mEq/L – headache, lethargy,

obtundation <110-115 mEq/L – altered mental

status/ seizures

CAUSES OF HYPONATREMIA

I. PseudohyponatremiaA. Normal plasma osmolality

1. Hyperlipidemia2. Hyperproteinemia3. Posttransurethral resection of

prostate/bladder tumorB. Increased plasma osmolality

1. Hyperglycemia2. Mannitol

CAUSES OF HYPONATREMIA

II. Hypoosmolal hyponatremiaA. Primary Na+ loss (secondary water gain)1. Integumentary loss: sweating, burns2. Gastrointestinal loss: vomiting, tube drainage, fistula, obstruction, diarrhea3. Renal loss: diuretics, osmotic diuresis, hypoaldosteronism, salt-wasting nephropathy, postobstructive diuresis, nonoliguric acute tubular necrosis

CAUSES OF HYPONATREMIA

B. Primary water gain (secondary Na+ loss)1. Primary polydipsia2. Decreased solute intake (e.g., beer potomania) 3. AVP release due to pain, nausea, drugs4. Syndrome of inappropriate AVP secretion5. Glucocorticoid deficiency6. Hypothyroidism7. Chronic renal insufficiency

CAUSES OF HYPONATREMIA

C. Primary Na+ gain (exceeded by secondary water gain)1. Heart failure2. Hepatic cirrhosis3. Nephrotic syndrome

Signs and Symptoms of Hyponatremia

The clinical manifestations of hyponatremia are related to osmotic water shift leading to increased ICF volume,

Therefore the symptoms are primarily neurologic, nausea and malaise. headache, lethargy, confusion, and

obtundation. Stupor, seizures, and coma <120 mmol/L or

decreases rapidly.

Four laboratory findings provide useful information and narrow the differential diagnosis of hyponatremia:

1. the plasma osmolality2. the urine osmolality3. the urine Na+ concentration4. the urine K+ concentration

Plasma Osmolality

Urine Osmolality

10/1/2010

272 374

Date Urine Na Urine K

10/1/2010 50 27.31

Creatinine

BUN

9/30/2010

0.91

10/1/2010

34.57

10/2/2010

0.87BUN/Crea Ratio34.57/0.9134.57/0.87

40:1 *>20:1 pre renal

azotemia

Patient is a known hypertensive since 2000; she is maintained on losartan + hydrochlorthiazide (Combivex) 50 mg/tab 1 tab OD and is compliant.

Diuretic Use

Hydrochlorothiazide Is a thiazide diuretic mainstay in

essential hypertension Acts by decreasing plasma volume and

thus decreasing cardiac output

Distal tubules

Diuretic-induced hyponatremia is almost always due to thiazide diuretics

Inhibits NaCl reabsorption at the luminal side of epithelial cells of the DCT, via the NCC transporter

Correction for Hyponatremia Goals are:

1. Raise the plasma Na concentration by restricting water intake and promoting water loss

2. Correct the underlying disorder

Correction for Hyponatremia Asymptomatic Hyponatremia

If Mild, requires no treatment If with ECF volume contraction

Na repletion with Isotonic Saline Solution

If with Edematous states Restriction of Na and water intake,

correction of hypokalemia, promotion of water loss in excess of Na (with use of loop diuretic and replacement of Urinary losses)

Correction for Hyponatremia Rate of correction

Depends on the presence or absence of neurologic symptoms [ (+) lethargy, GCS10 ] If asymptomatic, plasma Na concentration

should not be raised by no more than 0.5-1.0mmol/L per hour and by less than 10-12 mmol/L over the next 24 hours

Correction for Hyponatremia Rate of correction

If with severe hyponatremia (<110-115mmol/L) Treated with Hypertonic Saline and the

plasma Na concentration should be raised by 1-2mmol/L per hour for the 1st 3-4 hours or until seizures subside

Plasma concentration should not be raised by no more than 12mmol/L during the 1st 24 hours

Correction for Hyponatremia Rate of correction

(Desired Na – Actual Na) x wt. In kg x 0.5/0.6Date Na K

9/30/2010 111.44 4.41

10/1/2010 118 3.50

115 4.38

10/2/2010 120 3.36

126.67 3.99

126.32 3.92

10/3/2010 128.69 4.28

(120-111.44) x 70kg x 0.5 = ?(10) x 70 x 0.5 = 350 meq

Using PNSS In 1L PNSS 154meq

(350/154+100) x 1000 = ?(2.2) x 1000 =682.26cc

682.26/24hours = 28cc/hr monitor via infusion pump

*repeat serum Na after 4-6hours

Correction for Hyponatremia Rate of correction

(Desired Na – Actual Na) x wt. In kg x 0.5/0.6Date Na K

9/30/2010 111.44 4.41

10/1/2010 118 3.50

115 4.38

10/2/2010 120 3.36

126.67 3.99

126.32 3.92

10/3/2010 128.69 4.28

Actual Computation for our patient:10 x 0.7 x 0.5 = 350 meq

**add Urine Na loss at 50meq/LUO at 1450ml1.45L x 50 meq = 73 meq

Add total need + compensate for Urine Na loss 350 + 73 =423 meq

Actual Computation for our patient:10 x 0.7 x 0.5 = 350 meq

**add Urine Na loss at 50meq/LUO at 1450ml1.45L x 50 meq = 73 meq

Add total need + compensate for Urine Na loss 350 + 73 =423 meq

Fluid to be used is: 1L PNSS incorporated with 200 meq NaCl

1L PNSS = 154 meq154 + 200 meq = 354 meq

(423/354) x 1000 = 1194.9

1194.9/24 hours = 50cc/hr

So....Start IVF PNSS 1L + 200meq NaCl to run for 50cc/hr

Correction for Hyponatremia Rate of correction

If with severe hyponatremia (<110-115mmol/L) Treated with Hypertonic Saline and the

plasma Na concentration should be raised by 1-2mmol/L per hour for the 1st 3-4 hours or until seizures subside

Plasma concentration should not be raised by no more than 12mmol/L during the 1st 24 hours

Date

Time Na

9/30 9:00pm 111.4410/1 7:15am 115

5:40pm 11810/2 5:15am 120

1:50pm 126.679:51pm 126.32

10/3 11:00am

126

9:15pm 128.69

•9pm – 7am 10 hours

•115 – 111.44 = 3.56 mmol/L

•3.56 / 10 hours = 0.356mmol/L per

hour

•9pm – 5:40pm 20 hours118-111.44 = 6.56 mmol/L

•6.56 / 20 hours =0.328mmol/L per

hour

Thank you!