A CASE OF HYPONATREMIA

M. SNEHA

ROLL NO - 74 

3RD SEMISTER  

NOTE

• The following online e-log  aims at discussing our patients de-identified health data shared after taking the consent.

• I have been given this case to understand patients clinical data analysis to develop my skills in providing the treatment and diagnosis based on the history,investigations and clinical findings.

• Thanks to Pavan Kalyan Sir and Shashikala Mam for the guidance.

A 62 year old female resident of chityala has 3 children , presented to casuality in a irritable and altered state with complaints of 

• Vomiting (5-6 episodes) , Loose stools (2 episodes) since yesterday

HISTORY OF PRESENT ILLNESS :

➣ Patient was apparently asymptomatic 15 years ago 

➣ Then she had complaints of cough intermittently and SOB early morning.She was diagnosed to have emphysema secondary to biomass exposure.

➣ 6 Months back , she developed low grade fever , shortness of breath ( grade 2) 

➣ No bilateral pedal edema , orthopnea , PND.

➣ She went to nearby RMP and was diagnosed with typhoid and was on medical management.

➣ From one month the patient has dyspepsia , shortness of breath for which she went to hospital and was on medication [TAB PAN - 40 mg]

➣ From yesterday patient had vomitings ( 5-6 episodes) , non bilious , watery consistency and also loss of appetite.

PAST HISTORY :

➣ k/c/o HTN since 3-4 months (on TAB Telma - 40 mg)

➣ History of TB 30 years back and was on medication ATT for 6 months

➣ Not a k/c/o Epilepsy/Asthma

PERSONAL HISTORY :

➣ Appetite - lost

➣ Diet - mixed

➣ Bowel and Bladder - regular

➣ Addictions - No

➣ Allergies - No

FAMILY HISTORY :

➣ Not significant 

PHYSICAL EXAMINATION :

➣ Patient is agitated 

➣ Pallor - Yes

➣ Icterus - No

➣ Cyanosis - No

➣ Clubbing of fingers or toes - No

➣ Lymphadenopathy - No

➣ Edema of feet - No

VITALS : At the time of presentation 

➣ BP - 130/80 mm Hg

➣ Pulse - 90 bpm

➣ RR - 12 cpm

➣ SPO2 - 100 % at room air

➣ GRBS - 143 mg%

SYSTEMIC EXAMINATION :

CVS - 

➣ S1 , S2 heard 

➣ No thrills and murmurs 

RESPIRATORY SYSTEM -

➣ Dyspnoea is seen 

➣ Position on Trachea is central

➣ Breath sounds are vesicular

ABDOMEN -

➣ Shape - Scaphoid

➣ Tenderness - No

➣ Palpable mass - No

➣ Bowel sounds - Yes

CNS -

➣ Irritable

➣ Speech - Normal

REFLEXES - 

	Right	Left
Biceps	+	+
Triceps	+	+
Supinator	+	+
Knee	+	+
Ankle	+	+

INVESTIGATIONS :

30/07/2021

➣ RBS - 94 mg/dL

➣ Serum Sodium - 117 mm/l

➣ Urine Protein to Creatinine Ratio

• Spot urine protein - 10 mg/dL
• Spot urine creatinine - 21 mg/dL
• Ratio - 0.47

➣ Urine Sodium - 197 mmol/L

➣ Urinary Potassium - 35.2 mEq/L

➣ Urinary Chloride - 213 mmol/L

➣ Serum Osmolality - 234 mOSM/kg

➣ Liver function test - 

• Total Bilirubin - 1.44 mg/dL
• Direct Bilirubin - 0.32 mg/dL
• SGOT - 91 IU/L
• SGPT - 35 IU/L
• Alkaline Phosphate - 236 IU/L
• Total Proteins - 7.2 gm/dL
• Albumin - 4 gm/dL
• A/G Ratio - 1.26 

ABG -

• pH - 7.47
• pCO2 -29.7 mmHg
• pO2 - 95 mmHg
• HCO3 - 21.5 mmol/L
• St HCO3 - 23.7 mmol/L
• BEB - -0.7 mmol/L
• BEecf - -1.6 mmol/L
• TCO2 - 42.7 VOL
• O2 Sat - 94.7%
• O2 Count - 16.8 VOL%

2D ECHO -

• Dilated RA/RV with mild PAH
• Mild D shaped LV
• IVC Dilated , not collapsing
• No PE/LV clot

PROVISIONAL DIAGNOSIS :

➣ Hyponatremia decreased Evaluation

TREATMENT :

➣ IVF 3% NaCl @ 15 ml/hr for 4 hrs

➣ INJ Pantop 40mg/IV/OD

➣ INJ Zofer 8mg/PV/OD

➣ INJ Ceftriaxone 1mg/IV/BD

➣ IVF NS @ 75 ml/hr

➣ BP/PR Charting 2 nd HRLY

➣ GRBS charting 4 th HRLY

➣ Strict I/O Charting

30/07/2021 

• INJ Pantop 40mg/IV
• INJ Zofer 4mg/IV
• INJ Ceftriaxone 1mg/IV/BD

31/07/2021

• INJ Pantop 40mg/IV/BD
• INJ Zofer 4mg/IV/OD
• INJ Ceftriaxone 1mg/IV/BD

01/08/2021

• TAB Clonazepam 25 mg/PO/OD
• TAB Mirtazapine 15 mg/PO/OD
• INJ Pantop 40mg/IV/OD
• INJ Zofer 4mg/IV/OD
• INJ Ceftriaxone 1mg/IV/BD

➣ Vomitings subsided

➣ BP - 100/160mmHg

➣ PR - 104 bpm