ACID-BASE BALANCE 86 year old woman is admitted to the hospital after she had a

Question

ACID-BASE BALANCE 86 year old woman is admitted to the hospital after she had a seizure while waiting for swallow evaluation as outpatient. Family reports that the patient has baseline advanced dementia, which has been worsening over the last year. She is not verbal. Her Medical History: Dementia (NH resident, totally dependent in ADLIADL Activities of Daily Living/lnstrumental Activities of Daily Living), High Blood Pressure, constipation. Her physical examination: Nothing to be noted, except dry mouth and of the mucal mucosal membranes and tachycardia. Her neurological examination revealed a somnolent, non communicative patient CT of the head revealed no changes since previous exam one year ago: There is no acute parenchymal hemorrhage or extra axial fluid collection. There is severe, extensive parenchymal volume loss with ex vacuo dilatation of the lateral, third, and fourth ventricles. There are confluent areas of low attenuation in the white matter diffusely, consistent with extensive chronic small vessel ischemic changes. calcifications. There is no mass, mass effect, or midline shift. There are no bony lesions nor fractures. Extensive chronic small vessel ischemic changes. BMP showed Na+ 155. The water deficit was replaced with D5W at 125 cc/hr, with a gradual drop in the sodium level to normal. The patient became more alert but continued to refuse food. Questions 1. What do you think is going on? 2. What would you do? 3. What happened? 4. Which is the main goal of the treatment? How much fluid should you order? What type of fluid? How the correction of fluid should be made? Why? 5. What is your final diagnosis? 6. What are the risks of this condition? 7. What did we learn from this case?

Explanation / Answer

1. ANS: According to the given situation the poor oral intake (inadequate fluid intake) was clearly seen in advanced dementia, and it can finally leads to hypernatremia.

2. ANS: The best treament for this patient is to administer deficit needs of calculated free water is correct replacement. D5W was the best fluid to replace the deficit.

3. ANS: A swallow evaluation was ordered to patients. In the patient it can indicate the alternative nutrion need.

4. ANS: The main goal of this treatment is to correct the deficit water levels. It can be done by starting intravenous infusion with dextrose or saline solutions and correction should be made gradually. Rapid correction of hypernatremia is dangerous. Rapid lowering of sodium concentration with free water causes water to flow into brain cells and causes them to swell. This can lead to cerebral edema, potentially resulting in seizures and permanent brain damage.The amount of fluid needed to correct hypernatremia can be calculated by the formula

Change in serum Na+ = (infusate Na+ + infusate K+) - serum Na+/total body water + 1

5. ANS: The final diagnosis of the patient is Hypernatremia. It mainly happens because of dehydration (hypovolemia).

6. ANS: Hypernatremia if unattended causes shrinkage of brain cells causing altered sensorium, confusion and muscle spasms. If it is severe, it may cause seizures, coma and death.

7. ANS: The lesson I learnt from this case is, that in the case of elderly patients, their hydration status should be checked before putting them on restricted fluid/diet to carry out certain investigations.

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