DATA ON ADMISSION Universitair Ziekenhuis Gent
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1 DATA ON ADMISSION A 78-year-old lady comes in via the emergency ward. While advancing slowly her car in a traffic jam, she had developed a brief syncopal episode with loss of consciousness, making her bump into the trunk of the car in front of her. 1
2 DATA ON ADMISSION A 78-year-old lady comes in via the emergency ward. While advancing slowly her car in a traffic jam, she had developed a brief syncopal episode with loss of consciousness, making her bump into the trunk of the car in front of her. When questioning her she seems to give accurate answers, but after checking with the family, some of these answers appear to be wrong 2
3 DATA ON ADMISSION A 78-year-old lady comes in via the emergency ward. While advancing slowly her car in a traffic jam, she had developed a brief syncopal episode with loss of consciousness, making her bump into the trunk of the car in front of her. When questioning her she seems to give accurate answers, but after checking with the family, some of these answers appear to be wrong At laboratory check, she appears to have a serum sodium of 128 meq/l 3
4 DATA ON ADMISSION A 78-year-old lady comes in via the emergency ward. While advancing slowly her car in a traffic jam, she had developed a brief syncopal episode with loss of consciousness, making her bump into the trunk of the car in front of her. When questioning her she seems to give accurate answers, but after checking with the family, some of these answers appear to be wrong At laboratory check, she appears to have a serum sodium of 128 meq/l At the last blood check 4 months before, her serum sodium was 141 meq/l 4
5 DEFINITIONS? Is this mild, moderate or profound hyponatremia? 5
6 We define mild hyponatremia as a biochemical finding of a sodium concentration as measured in serum or plasma by ion specific electrode between mmol/l. We define moderate hyponatremia as a biochemical finding of a sodium concentration as measured by ion specific electrode in serum or plasma between mmol /l. We define profound hyponatremia as a biochemical finding of a sodium concentration in serum or plasma as measured by ion specific electrode below 125 mmol/l. 6
7 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l 7
8 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? 8
9 We define acute hyponatremia as hyponatremia that is documented to exist less than 48 hours. We define chronic hyponatremia as hyponatremia that is documented to exist for at least 48 hours. If the patient cannot be classified, we consider him/her as chronic, unless there is clinical/anamnestic evidence for the contrary. 9
10 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? 10
11 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. 11
12 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. 12
13 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Is this moderately or severely symptomatic hyponatremia? 13
14 DEFINITION ON BASIS OF SYMPTOMS Moderately severe Nausea Confusion Headache Lethargy Severe Vomiting Cardio-respiratory distress Somnolence Seizures Coma (Glasgow coma scale < or = 8) 14
15 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Is this moderately or severely symptomatic hyponatremia? Moderately severe. 15
16 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Is this moderately or severely symptomatic hyponatremia? Moderately severe. Is this non-hypotonic or hypotonic hyponatremia? 16
17 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Is this moderately or severely symptomatic hyponatremia? Moderately severe. Is this non-hypotonic or hypotonic hyponatremia? For this we need serum osmolality. 17
18 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Is this moderately or severely symptomatic hyponatremia? Moderately severe. Is this non-hypotonic or hypotonic hyponatremia? For this we need serum osmolality: 256 meq/l. 18
19 SUMMARY This is a moderate and hypotonic hyponatremia with moderately severe symptoms. 19
20 SUMMARY This is a moderate and hypotonic hyponatremia with moderately severe symptoms. We cannot ascertain whether this hyponatremia is acute or chronic. Thus, it should be considered as chronic. 20
21 APPROACH? 21
22 APPROACH? History Clinical status Biochemistry Therapy 22
23 HISTORY Depression Migraine Tension headache Tremor Arthrosis deformans Hypertension Paroxysmal atrial fibrillation Normal thyroid function (2011) Cerebral atrophy (MRI) (2011) Bilateral pyelonephritis (2012) 23
24 HISTORY Depression Migraine Tension headache Tremor Arthrosis deformans Hypertension Paroxysmal atrial fibrillation Normal thyroid function (2011) Cerebral atrophy (MRI) (2011) Bilateral pyelonephritis (2012) Is the history satisfactory like this? 24
25 HISTORY RECENT COMPLAINTS Drop attacks (without loss of consciousness) Fatigue since few months Somnolence since few months Generalized pains Incontinence Ructus One single episode of diarrhea the night before No fever 25
26 HISTORY RECENT COMPLAINTS Drop attacks (without loss of consciousness) Fatigue since few months Somnolence since few months Generalized pains Incontinence Ructus One single episode of diarrhea the night before No fever Which complaints may be important here? 26
27 HISTORY RECENT COMPLAINTS Drop attacks (without loss of consciousness) Fatigue since few months Somnolence since few months Generalized pains Incontinence Ructus One single episode of diarrhea the night before No fever 27
28 HISTORY RECENT COMPLAINTS Drop attacks (2 or 3 last months without loss of consciousness) Fatigue since few months Somnolence since few months Generalized pains Incontinence Ructus One single episode of diarrhea the night before No fever 28
29 HISTORY RECENT COMPLAINTS Drop attacks (2 or 3 last months without loss of consciousness) Fatigue since few months Somnolence since few months Generalized pains Incontinence Ructus One single episode of diarrhea the night before No fever LET US RECONSIDER DEFINITION 2 NOW (CHRONIC VS. ACUTE) 29
30 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l. Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Is this moderately or severely symptomatic hyponatremia? Moderately severe. Is this non-hypotonic or hypotonic hyponatremia? For this we need serum osmolality: 256 meq/l. 30
31 DEFINITIONS? Is this mild, moderate or profound hyponatremia? Moderate hyponatremia: 128 is in between125 and 129 meq/l Is this acute or chronic hyponatremia? We cannot define this case. The last available data are from 4 months before and were normal. Given these circumstances we have to consider the case as chronic. Some complaints are there already since a few months: so probably chronic Is this moderately or severely symptomatic hyponatremia? Moderately severe. Is this non-hypotonic or hypotonic hyponatremia? For this we need serum osmolality: 256 meq/l. 31
32 HISTORY RECENT COMPLAINTS Drop attacks (2 or 3 last months without loss of consciousness) Fatigue since few months Somnolence since few months Generalized pains Incontinence Ructus One single episode of diarrhea the night before No fever Is the history satisfactory like this? 32
33 HISTORY - MEDICATION Which drugs would you consider most important? 33
34 HISTORY - MEDICATION Omeprazole Aspirin Warfarin Desmopressin (for incontinence) (start 3m before admission) Bisoprolol Olmesartan Hydrochlorothiazide Digoxin Pravastatin Escitalopram (Sipralexa SSRI) Amitriptyline (Redomex) Oxybuturine (for incontinence) Vitamin D3 34
35 HISTORY - MEDICATION Omeprazole Aspirin Warfarin Desmopressin (for incontinence) Bisoprolol Olmesartan Hydrochlorothiazide Digoxin Pravastatin Escitalopram (Sipralexa SSRI) Amitriptyline (Redomex) Oxybuturine (for incontinence) Vitamin D3 Which one(s) do you consider important? 35
36 HISTORY - MEDICATION Omeprazole Aspirin Warfarin Desmopressin (for incontinence) Bisoprolol Olmesartan Hydrochlorothiazide Digoxin Pravastatin Escitalopram (Sipralexa SSRI) Amitriptyline (Redomex) Oxybuturine (for incontinence) Vitamin D3 36
37 HISTORY - MEDICATION Omeprazole Aspirin Warfarin Desmopressin (for incontinence) Bisoprolol Olmesartan Hydrochlorothiazide Digoxin Pravastatin Escitalopram (Sipralexa SSRI) Amitriptyline (Redomex) Oxybuturine (for incontinence) Vitamin D3 37
38 CLINICAL STATUS What would you look for first? 38
39 VOLUME STATUS Hypervolemia Hypovolemia Normovolemia 39
40 VOLUME STATUS Hypervolemia Peripheral edema Pulmonary edema Hypovolemia Normovolemia 40
41 VOLUME STATUS Hypervolemia Peripheral edema Pulmonary edema Hypovolemia Dry skin Dry tongue Flattened neck veins Decreased skin turgor Decreased eyeball turgot Hypotension Orthostatism Tachycardia Normovolemia 41
42 VOLUME STATUS Hypervolemia Peripheral edema Pulmonary edema Hypovolemia Dry skin Dry tongue Flattened neck veins Decreased skin turgor Decreased eyeball turgot Hypotension Orthostatism Tachycardia Normovolemia 42
43 CLINICAL STATUS What would you look for? 43
44 CLINICAL STATUS Blood pressure: 99/63 mm Hg Pulse: 72/min T : 36.1 C General status: OK Cognitive: slow, not entirely accurate Neuro: slight vertigo Heart: irregular, no bruits Lungs: OK Abdomen: OK, no globus Back: OK, no pain at percussion kidney zone 44
45 CLINICAL STATUS Blood pressure: 99/63 mm Hg Pulse: 72/min T : 36.1 C General status: OK Cognitive: slow, not entirely accurate Neuro: slight vertigo Heart: irregular, no bruits Lungs: OK Abdomen: OK, no globus Which one(s) do you consider important? Back: OK, no pain at percussion kidney zone 45
46 CLINICAL STATUS Blood pressure: 99/63 mm Hg Pulse: 72/min T : 36.1 C General status: OK Cognitive: slow, not entirely accurate Neuro: slight vertigo Heart: irregular, no bruits Lungs: OK Abdomen: OK, no globus Back: OK, no pain at percussion kidney zone 46
47 CLINICAL STATUS Blood pressure: 99/63 mm Hg Dehydration? Overtreatment? Pulse: 72/min T : 36.1 C General status: OK Cognitive: slow, not entirely accurate Neuro: slight vertigo Heart: irregular, no bruits Lungs: OK Abdomen: OK, no globus Back: OK, no pain at percussion kidney zone 47
48 CLINICAL STATUS Blood pressure: 99/63 mm Hg Dehydration? Overtreatment? Additional info? 48
49 CLINICAL STATUS Blood pressure: 99/63 mm Hg Dehydration? Overtreatment? Additional info? Orthostatism? 49
50 CLINICAL STATUS Blood pressure: 99/63 mm Hg Dehydration? Overtreatment? Additional info? Orthostatism? 113/67 sitting 95/55 standing 50
51 BIOCHEMISTRY What would you look for? 51
52 BIOCHEMISTRY Glycemia Lipidemia Plasma protein Uric acid Urea Serum creatinine egfr Urinary sodium Urinary osmolality FENa 52
53 BIOCHEMISTRY Glycemia: 53
54 BIOCHEMISTRY Glycemia (hypotonic): 54
55 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia: 55
56 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): 56
57 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 57
58 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 58
59 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 59
60 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 56 mg/dl (before 29) 10 mmol/l Serum creatinine: 60
61 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 56 mg/dl (before 29) 10 mmol/l Serum creatinine: 1.08 mg/dl (before 0.91) mmol/l egfr: 61
62 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 56 mg/dl (before 29) 10 mmol/l Serum creatinine: 1.08 mg/dl (before 0.91) mmol/l egfr: 57 ml/min Urinary sodium: 62
63 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 56 mg/dl (before 29) 10 mmol/l Serum creatinine: 1.08 mg/dl (before 0.91) mmol/l egfr: 57 ml/min Urinary sodium: 80 meq/l Urinary osmolality: 63
64 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 28 mg/dl (before 29) 10 mmol/l Serum creatinine: 1.08 mg/dl (before 0.91) mmol/l egfr: 57 ml/min Urinary sodium: 80 meq/l Urinary osmolality: 619 meq/l FENa: 64
65 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia (hypotonic): triglyceridemia not checked Plasma protein: 67 g/l (before 60) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 56 mg/dl (before 29) 10 mmol/l Serum creatinine: 1.08 mg/dl (before 0.91) mmol/l egfr: 57 ml/min Urinary sodium: 80 meq/l Urinary osmolality: 619 meq/l FENa: 8% 65
66 BIOCHEMISTRY Glycemia (hypotonic): 0.99 mg/dl 55 µmol/l Lipidemia: triglyceridemia not checked Plasma protein: 67 g/l (before 6.0) Uric acid: 6.0 mg/dl (before 5.9) mmol/l Urea: 28 mg/dl (before 29) 5 mmol/l Serum creatinine: 1.08 mg/dl (before 0.91) mmol/l egfr: 57 ml/min Urinary sodium: 80 meq/l Urinary osmolality: 619 meq/l FENa: 8% CONCLUSIONS? 66
67 CONCLUSIONS? At admission the lady was seemingly euvolemic (no edema) but there were clinical and biochemical signs of volume depletion (diarrhea, orthostatism, increase in serum creatinine and urea). 67
68 CONCLUSIONS? At admission the lady was seemingly euvolemic (no edema) but there were clinical and biochemical signs of volume depletion (diarrhea, orthostatism, increase in serum creatinine and urea). All results could however be explained as well by slight hypoperfusion due to overtreatment of hypertension 68
69 CONCLUSIONS? At admission the lady was seemingly euvolemic (no edema) but there were clinical and biochemical signs of volume depletion (diarrhea, orthostatism, increase in serum creatinine and urea). All results could however be explained as well by slight hypoperfusion due to overtreatment of hypertension Urinary Na and FENa? 69
70 CONCLUSIONS? At admission the lady was seemingly euvolemic (no edema) but there were clinical and biochemical signs of volume depletion (diarrhea, orthostatism, increase in serum creatinine and urea). All results could however be explained as well by slight hypoperfusion due to overtreatment of hypertension Urinary Na and FENa? May be due to desmopressin but also to antidepressants, diuretic and ARB 70
71 CONCLUSIONS? At admission the lady was seemingly euvolemic (no edema) but there were clinical and biochemical signs of volume depletion (diarrhea, orthostatism, increase in serum creatinine and urea). All results could however be explained as well by slight hypoperfusion due to overtreatment of hypertension Urinary Na and FENa? May be due to desmopressin but also to antidepressants, diuretic and ARB Renal function acceptable 71
72 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 72
73 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 9/1/13, blood pressure: 108/69 (16.00) & 116/63 (20.00). 73
74 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 9/1/13, blood pressure: 108/69 (16.00) & 116/63 (20.00). Stop Desmopressin, Olmesartan, Hydrochlorothiazide, Amitriptyline 74
75 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 9/1/13, blood pressure: 108/69 (16.00) & 116/63 (20.00). Stop Desmopressin, Olmesartan, Hydrochlorothiazide, Amitriptyline 10/1/13 (08.00): Na 137 meq/l; blood pressure 134/80 75
76 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 9/1/13, blood pressure: 108/69 (16.00) & 116/63 (20.00). Stop Desmopressin, Olmesartan, Hydrochlorothiazide, Amitriptyline 10/1/13 (08.00): Na 137 meq/l; blood pressure 134/80 11/1/13 (discharge) (10.00): Na 137 meq/l 76
77 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 9/1/13, blood pressure: 108/69 (16.00) & 116/63 (20.00). Stop Desmopressin, Olmesartan, Hydrochlorothiazide, Amitriptyline 10/1/13 (08.00): Na 137 meq/l; blood pressure 134/80 11/1/13 (discharge) (10.00): Na 137 meq/l Clinical status OK 77
78 THERAPY AND EVOLUTION On admission (9/1/13, 09.30), with Na 128 meq/l, start isotonic saline (9 g/l) till next morning. Then slow maintenance infusion with half isotonic saline. 9/1/13, blood pressure: 108/69 (16.00) & 116/63 (20.00). Stop Desmopressin, Olmesartan, Hydrochlorothiazide, Amitriptyline 10/1/13 (08.00): Na 137 meq/l; blood pressure 134/80 11/1/13 (discharge) (10.00): Na 137 meq/l Clinical status OK 30/1/13 (10.00): Na 144 meq/l 78
79 DO YOU AGREE WITH THIS APPROACH? Serum sodium corrected at the borderline of the acceptable speed range: 11 meq/l for 23 hours vs. recommended maximum 10 meq/l per 24 hours. 79
80 DO YOU AGREE WITH THIS APPROACH? Serum sodium corrected at the borderline of the acceptable speed range: 11 meq/l for 23 hours vs. recommended maximum 10 meq/l per 24 hours. As the hyponatremia was only moderate this likely does not harm however. 80
81 DO YOU AGREE WITH THIS APPROACH? Serum sodium corrected at the borderline of the acceptable speed range: 11 meq/l for 23 hours vs. recommended maximum 10 meq/l per 24 hours. As the hyponatremia was only moderate this likely does not harm however. Of course, the patient was also volume depleted. 81
82 DO YOU AGREE WITH THIS APPROACH? Serum sodium corrected at the borderline of the acceptable speed range: 11 meq/l for 23 hours vs. recommended maximum 10 meq/l per 24 hours. As the hyponatremia was only moderate this likely does not harm however. Of course, the patient was also volume depleted. It may have made sense to give isotonic saline only until recovery of blood pressure and then slow down administration. 82
83 DO YOU AGREE WITH THIS APPROACH? Serum sodium corrected at the borderline of the acceptable speed range: 11 meq/l for 23 hours vs. recommended maximum 10 meq/l per 24 hours. As the hyponatremia was only moderate this likely does not harm however. Of course, the patient was also volume depleted. It may have made sense to give isotonic saline only until recovery of blood pressure and then slow down administration. Alternatively, half isotonic saline, glucose or colloids might have been considered after normaization of blood pressure. 83
84 DO YOU AGREE WITH THIS APPROACH (2)? 84
85 DO YOU AGREE WITH THIS APPROACH (2)? No control of serum sodium for almost 24 hrs. 85
86 DO YOU AGREE WITH THIS APPROACH (2)? No control of serum sodium for almost 24 hrs. Also urine volume was not assessed while repleting. 86
87 DO YOU AGREE WITH THIS APPROACH (2)? No control of serum sodium for almost 24 hrs. Also urine volume was not assessed while repleting. In absence volume depletion stop therapy could have been enough. 87
88 SUMMARY This is a 78-year-old lady with a moderate, probably chronic, moderately symptomatic, hypotonic hyponatremia. 88
89 SUMMARY This is a 78-year-old lady with a moderate, probably chronic, moderately symptomatic, hypotonic hyponatremia. The time course suggests that the hyponatremia is linked to the start of Desmopressin 3 months before the episode, as serum sodium was normal 4 months before. 89
90 SUMMARY This is a 78-year-old lady with a moderate, probably chronic, moderately symptomatic, hypotonic hyponatremia. The time course suggests that the hyponatremia is linked to the start of Desmopressin 3 months before the episode, as serum sodium was normal 4 months before. Aggravating factors are: intake of hydrochlorothiazide, an ARB, and antidepressants, and possibly a brief episode of diarrhea the night before. 90
91 SUMMARY This is a 78-year-old lady with a moderate, probably chronic, moderately symptomatic, hypotonic hyponatremia. The time course suggests that the hyponatremia is linked to the start of Desmopressin 3 months before the episode, as serum sodium was normal 4 months before. Aggravating factors are: intake of hydrochlorothiazide, an ARB, and antidepressants, and possibly a brief episode of diarrhea the night before. The patient was likely volume depleted at admission. 91
92 SUMMARY This is a 78-year-old lady with a moderate, probably chronic, moderately symptomatic, hypotonic hyponatremia. The time course suggests that the hyponatremia is linked to the start of Desmopressin 3 months before the episode, as serum sodium was normal 4 months before. Aggravating factors are: intake of hydrochlorothiazide, an ARB, and antidepressants, and possibly a brief episode of diarrhea the night before. The patient was likely volume depleted at admission. Repletion was too fast. 92
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