CASE STUDY- MR.

H
CHEYENNE TATE
ROTATION: MED I- MRS. HAARBURGER
BACKGROUND

Hyponatremiaserum
sodium <130 mEq/L

Hypertonic-water
Isotonic-net salt and Hypotonic-salt loss in
loss alone, or water in
water loss are equal excess of water loss
excess of salt
ETIOLOGY

Sweating >3% of total body weight

Decreased intake over several months
Drinking large amounts of water/alcohol
Beer-potomania, psychogenic polydipsia
Anorexia/bulimia
GI losses in diarrhea, vomiting, GI suctioning, GI surgery
Salt-wasting kidney disease
Excessive/inappropriate use of diuretics SIADH
Hypervolemia due to
CHF, cirrhosis, nephrosis
Burns
Large skin wounds
SYMPTOMS

Nonspecific Severe
Headache
Seizures
Nausea
Vomiting Coma
Fatigue Respiratory
Gait disturbances Arrest
Confusion Obtundation
MR. H. ADMISSION 10.17.17

66yo AAM male

PMH: NICM, OSA, HTN, CKD, DM2, EtOH-induced Dementia, MDD, Anxiety, Lumbar spinal stenosis, BPH, RUL
mass, RUL nodule and thyroid nodule
Symptoms:
3 day productive cough
Fevers/chills
Diarrhea 3x day
Decreased PO intake
Increased confusion
DIAGNOSIS

DX: LEGIONELLA PNEUMONIA

FULL MEDS

ACETAMINOPHEN ALBUTEROL PRN DEXTROSE

TAB QID PRN FOR FOR SHORTNESS AMLODIPINE TAB ASPIRIN ATORVASTATIN BUPROPION 24GM/31GM ORAL
FEVER OF BREATH (GLUCOSE)

GUAIFENESIN PRN
DEXTROSE 50% IN FERROUS SULFATE HYDRALAZINE TAB
GLUCAGON INJ COUGHING/CHEST HEPARIN TID LEVOFLOXACIN
WATER INJ,SOLN TAB 325MG PO BID 50MG PO TID
CONGESTION

LOPERAMIDE PO
TRAZODONE PRN
LISINOPRIL BID QID PRN MELATONIN PRAZOSIN HCL SERTRALINE
insomnia
DIARRHEA
NUTRITIONAL IMPOSING MEDICATIONS

Ferrous sulfate BID

Atorvastatin- statin
Amlodipine- HTN
Glucagon, dextrose, lancet
Heparin- anticoagulant
Loperamide- Anti-Diarrheal
Non Va:
multivitamin, B-50 complex
 ANTHROPOMETRICS

Height 60 (183 cm)

Weight 268.5 lbs (122 kg)
Usual Weight: 272 lbs (123.6 kg)
% Usual Wt: 99%
Body Mass Index: obese 36.5
Wt Loss: 8# (insignificant) 3mo

GOAL: Weight maintenance 268#

COMPARATIVE STANDARDS

Energy Requirements: 2020 Kcal/day

Mifflin-St Jeor, and Actual Body Wt
Protein Requirements: 98 gm
Actual Body Wt and protein level of 0.8
Fluid Requirements: 2020 ml/day or per MD
 Laboratory Data
Test Result units Ref. range
ALBUMIN 2.5 L g/dL 3.4 - 5.5 Medical status, pneumonia
BUN 16 mg/dL 8 - 20
CREATININE 1.0 mg/dL 0.5 - 1.2
GLUCOSE 134 H mg/dL 70 - 120
Controlled T2DM
HEMOGLOBIN A1C 6.5 H % 3.0 - 6.1
POTASSIUM 3.3 L mmol/L 3.5 - 5.0
PHOSPHORUS 2.5 mg/dL 2.5 - 4.9
SODIUM 129 L mmol/L 136 - 148 Hyponatremic
CALCIUM 8.3 L mg/dL 8.5 - 10.1
WBC COUNT 8.58 K/cmm 3.6 - 11.0
HGB 11.9 L g/dL 13.6 - 17.4 Normocytic anemia
HCT 34.7 L % 40 - 51
MCV 85.9 cmu 80 - 96
FERRITIN 84 ng/mL 25 - 250
VITAMIN B12 763 pg/mL 150 - 900
EGFR (CALCULATED) 90 60
LYMPHS % 14.6 L % 21 - 51
CO2 22 mmol/L 21 - 32
MAGNESIUM 2.2 mg/dL 1.8 - 2.4
PROTEIN, TOTAL 7.7 g/dL 6.4 - 8.5
CHLORIDE 98 mmol/L 98 - 107
 NUTRITION DIAGNOSES

Altered nutrition-related
Energy
Inadequate energy intake laboratory values
Biochemical
Balance

decreased appetite and fatigue, Legionella pneumonia, poor po

Related to: legionella pneumonia infection Related to: intake, GI losses through diarrhea

Veteran/wife report, 8# Serum sodium value of129

As evidenced
by:
unintentional weight loss. As evidenced
by:
INTERVENTION

MEALS AND SNACKS

Continue with 3GM sodium diet

If no need for NA restriction, advance to

regular. No need for CC due to DM control
& low intake.
GOALS & MONITORING

Adequate po intake of >=75% of meals/supplements over the next three days

Weight maintenance at ~268#

EDUCATION: per nutrition assessment 10/17

Educated and reviewed on low CHO food, blood sugar readings, foods that are high in sodium,
processed foods, blood pressure readings"
FOLLOW UP 10/19

Veteran had low po intake persisting into 10/19

Breakfast: coffee
Lunch: fruit

Plan Adjustment
Supplemental feedings of fruit
Antiemetic ordered
REFERENCES

Sterns R, MD. Overview of the treatment of hyponatremia in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate
Inc. http://www.uptodate.com (Accessed on October 18, 2017.)
Sahay M, Sahay R. Hyponatremia: A practical approach. Indian Journal of Endocrinology and Metabolism.
2014;18(6):760-771. doi:10.4103/2230-8210.141320.