Please help me answering the following questions for the clinical case: 86 year
ID: 93498 • Letter: P
Question
Please help me answering the following questions for the clinical case:
86 year old woman is admitted to the hospital after she had a seizure while waiting for swallow evaluation as the 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 ADL/IADL Activities of Daily Living/Instrumental Activities of Daily Living), High Blood Pressure, Constipation.
Her physical examination: Nothing to be noted, except the dry mouth and of the mural mucosal membranes and tachycardia. Her neurological examination revealed a somnolent, non-communicative patient.
CT of the head revealed no changes since the previous test one year ago: There is no acute parenchymal hemorrhage or extra-axial fluid collection. It 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:
What do you think is going on?
What would you do?
What happened?
Which is the main goal of the treatment? How much fluid should you order? What type of fluid? How should the correction of fluid be made? Why?
What is your final diagnosis?
What are the risks of this condition?
What did we learn from this case?
Explanation / Answer
The patient had developed hypernatremia due to inadequate fluid intake.
The treatment here is to administer free water to correct the water deficit.
As the patient was waiting for swallow evaluation, she might be on fluid restriction for few hours which has resulted in this condition. This is typically seen in elderly.
The main goal of the treatment is to correct the water deficit. This 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,
Final diagnosis is dehydration with hypernatremia.
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.
The lesson learnt from this case is that in case of elderly patients, their hydration status should be checked before putting them on restricted fluid/diet to carry out certain investigations.
Total H2O deficit (L) = total body water x ( 1 - ) desired Na+serum Na+
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