-- ABCs: if Na >160 and AMS, consider ICU for close monitoring and q1-2 lab draws
-- Chart Check: h/o DI, dementia, substance use, immobility, brain pathology
-- Can't Miss: *** sepsis, cause of patient havign AMS or being found down (stroke, seizure, syncope, etc)
-- Admission Orders: CBC, BMP, Calcium, serum and urine Osm
-- Initial Treatment to Consider: fluids to correct FWD
-- History: *** long-term care facility, dementia, immobile, diuretic use
-- Clinical: *** fevers, AMS, N/V/D, polyruia/polydipsia
-- Exam: *** volume assessment, AMS, hyperreflexia, weakness
-- Data: *** Free-water Deficit (FWD), calcium
-- Etiology: decreased access to free water, AMS, decreased thirst drive, diabetes insipidus, post-ATN, loop diuretics, hyperCa, insensible losses, N/V/D
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- Monitoring: ***BMP q ***; Strict I/O
-- Send urine Osm if c/f renal mechanism or DI - will be <600-800
-- If e/o DI - renal consult to trial desmopressin to distinguish central vs peripheral (cental will respond, nephrogenic will not)
-- Free Water: *** (PO, free water flush, D5W IV) to address FWD of *** plus *** of expected insensible losses
-- if c/f DI, Consider Na restriction <2g per day
The current free water deficit is ***. Accounting for insensible losses, we should continue to replete with *** at a rate of *** in order to decrease the sodium level *** over 24 hours.
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Hypernatremia is most commonly caused by poor PO intake and/or insensible losses. In general, hypernatremia is rarely the sole cause of presenation, and is usually a result of another process; it may be a reflection of either poor PO intake or insensible losses secondary to other acute illnesses like infection/sepsis or a fall 2/2 intoxication, syncope or seizures. You should calculate the free water deficit and replete via D5W. Never bolus free water, but instead give it as a maintenance fluid with a goal to correct 8-12 over a 24 hour period. A complication of rapid correction is cerebral edema, but this is rarely seen in adults. If you accidentally bolus free water, touch base with renal consultants to discuss giving hypertonic 3% saline to re-correct. If the hypernatremia does not correct with replacement of free water, you can begin thinking about other etiologies like diabetes insipidus.