DrVirgo
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A 63-year-old man is admitted to the hospital for management
of pneumococcal pneumonia.He has been previously
healthy until he developed fevers and a cough
productive of brownish sputum. He is admitted for
administration of intravenous antibiotics. Over the next
few days, he is noted to be progressively lethargic and
confused. Evaluation for meningitis, including a lumbar
puncture, is negative. A CT scan of the head is negative.
Chest x-ray reveals a persistent pneumonia in the right
lower lobe. His serum sodium is 125 mEq/L. Blood cultures
and remaining laboratory studies are normal. His
jugular venous pressure is 9 cm H2O. Examination
reveals crackles in the right lower lung field. He has no
pedal edema. The patient has been eating fairly well and
has not been noted to be aspirating.His fractional excretion
of sodium (FeNa) is 0.5%.Which of the following
is the most appropriate management?
(A) Administer a bolus of normal saline
(B) Administer furosemide
(C) Administer salt tablets
(D) Expand antibiotic coverage
(E) Restrict fluid to 1 L of water daily
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| robin082006
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E
this is overhydration
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| Aashi
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Pneumonia--->SIADH-->euvolemic hyponatremia-->first step H20 restriction, but since pt has already become lethargic and confused ,i think hypertonic NA shld be given..
Edited by Aashi on 02/06/07 - 06:20 PM
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| drashishmahajan
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salt tablets... symptomatic patient
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| webjeee
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what's the answer?
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| young_doc
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I think this patient has hypervolemic hyponatremia...and not a euvolemic hyponatremia:
-bilateral crackles (x-ray revealed pneumonia only on 1 side)
-increased JVP
Restricting fluid intake is a better treatment.
Answer is E.
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| DrVirgo
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E. The patient most likely has the
syndrome of inappropriate secretion of antidiuretic
hormone (SIADH), in which he is in a sodium-wasting
state and is retaining free water. A pulmonary process
can induce SIADH. The patient should be placed on
free water restriction until the sodium level normalizes
gradually. The diagnosis may be confirmed with simultaneous
measurement of plasma and urine osmolarity.
Administering fluid (choice A) may worsen the
hyponatremia by effectively inducing the kidneys to
retain free water while wasting sodium.
A loop diuretic (choice B) would cause sodium wasting
and worsen the hyponatremia.
Similarly, salt tablets (choice C) would not correct
SIADH.
The patient is being treated with antibiotics currently
and he has not necessarily failed treatment (choice D).
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| Aashi
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[young_doc]I think this patient has hypervolemic hyponatremia...and not a euvolemic hyponatremia:
Dear youngdoc..SIADH is characterized by HYPOSMOTIC HYPONATREMIA,Urine osmolality > than plasma osmolality and EUVOLEMIA( or normovolemia)-->ECF is not contracted, infact mildly explanded-->and this one reason why SIADH pts doesnt have EDEMA--->coz NA levels are normal in these guys! AND MOST IMPO CRITERIA IS that, ALL THIS SHLD HAPPEN-->in the presence of NORMAL kidney thyroid and adrenal functions..
SIADH pts has NORMAL NA levels but the due to inappro ADH sec ,water retention is too much-->hyponatremia...Another point to be noted is SIADH pts has HYPOURICEMIA-->if u know,hypovolemic pts normally has HYPERURICEMIA--> Due to increased urate absorption in prox tubules..
ANY CONDITIONS in the LUNG--> SIADH not neccessarily ONLY lung CA..
I just gave u a breif description of SIADH,if u want to learn more on this,plss refer HARRISONS,i did electrolyte imbalance from that book..electrolyte imbalance is an impo topic for the exam..thatz y i thought of putting across a few points on this impo topic..
GL
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| Dr.Luck
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I got it ...if we give NS then it will increase both water & Na & thus no effect on Na levels & there won't be any improvemnet so we either need to give him Hypertonic saline or restrict fluids so my answer would be restrict fluids as hypertonice fluid isn't in the options.
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| Dr.Luck
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giving salt tablets will take too long to get absorbed & produce it's effects
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| drhutch
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serum sodium level s
130 -120 restrict water.
120 - 110 restrict water + diuretics
less than 110 hypertonic saline
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