Perhaps
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A 67yo man is brought to the ER by his wife because of a 3 day history of progressive sleepiness. Over the past year, he has had intermittent night sweats and a 9-kg (20-lb) weight loss with no change in appetite. He has a 2-year history of a nonproductive cough treated with inhaled nasal corticosteroid therapy. He has smoked two packs of cigarettes daily for 40 years and does not drink alcohol. He is somnolent and oriented to person but not to place or time. His temperature is 37.1°C (98.8°F), pulse is 96/min, respirations are 16/min, and blood pressure is 120/85 mm Hg. Examination shows a supple neck with fullness in the left supraclavicular fossa. Breath sounds are decreased on the left. There is dullness to percussion at the left lung base. Neurologic examination shows no focal findings. Pulse oximetry on room air shows an oxygen saturation of 90%. A complete blood count is within the reference range, and serum calcium level is 14 mg/dL. Urinalysis shows a sodium level less than 5 mmol/L and a fractional sodium excretion less than 1%. An x-ray film of the chest shows a large left pleural effusion. The most appropriate next step in management is administration of which of the following?
A) Intravenous bisphosphonate
B) Intravenous 5% dextrose in 0.45% saline
C) Intravenous 5% dextrose in water
D) Intravenous 0.9% saline
E) Oral loop diuretic
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| frank100
Forum Guru
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sodium levels mut be low, since the kidney is trying to retain as much as it can...I think this is SIADH due to lung cancer. Hypercalcemia of malignancy can be adressed by normal saline, if it doesn´t work, biphosphonates.
calcium levels are horrible, but dilution is a good way to start, at least for me.
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| mazinger
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D
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| HighHopes
Forum Senior
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I would go with D
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| Naca
Forum Newbie
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B
She has probably lung cancer with cerebral disemination that is the reason for her sleepiness.
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| webjeee
Forum Guru
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must be E
reduce both na and ca retention.
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| fox
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agree with webjee....addresses both issues
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| krsna
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BUT SIADH HAS ELEVATED SODIUM CONCENTRATION IN THE URINE(MORE THAN 20 MMOL/L)...THIS DOESNT FIT THE BILL OF SIADH..
I WOULD GO FOR THE ANS D ANYWAYS..
CORRECT ME IF IM WRONG...
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| dr.shailu
Forum Senior
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yes, ADH causes retention of only water and some urea but not sodium in collecting tubules.
so answer is D -I V normal saline
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| fongch
Forum Elite
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IMHO, the patient has hypercalcemia 2ary to malignancy (PTHrP, most likely) ONLY. Therefore D is the most reasonable step.
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| usmle12
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YUP D
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