An elderly female with depression presents with fall, found to be hyponatremic to 112. This was ultimately though secondary to celexa, and improved with gentle fluids as well as holding that medication. During her work-up, an adrenal incidentaloma was discovered; we discussed the recommended management of these.
*When is hyponatremia severe enough to merit use of hypertonic saline?
-although expert panel recommendations include the use of hypertonic saline for a range of symptoms and sodium levels (see below), it is onlyabsolutely indicated for patients with acute hyponatremia w/ severe symptoms (coma, seizures, obtundation, respiratory arrest)
-see review for recommended rates of correction and what to do when someone is correcting too quickly
*Approach to adrenal incidentaloma:
-incidental benign adrenal nodes are COMMON, especially as people get older
-Dr. Kanter quoted 4cm as the size above which adrenal nodes should be surgically removed
A middle aged female with no PMHx presents with anxiety and palpitations, found to have mild sinus tachycardia (HR 129) without evidence of thyroid storm.
1) Thyroid storm is a CLINICAL diagnosis that requires AMS + FEVER. TSH/T4/T3 levels do not help distinguish storm from other hyperthyroid conditions.
2) The two most common causes of hyperthyroidism are GRAVES and THYROIDITIS. Time course helps distinguish these (Graves is chronic, Thyroiditis acute to subacute)*
There was a great review article on Hyperthyroidism in The Lancet this year (see attached)
An elderly gentleman with a pmh of CAD who presented with 6 months of progressive confusion and global weakness admitted for hypercalcemia also found to have a new anemia and AKI.
Know workup of hypercalcemia – think about malignancy in hospitalized patients!
-1,25 Vit D for granulomatous process (sarcoid)
-25 Vit D level for vitamin D toxicity
-Milk Alkali Syndrome
Acute treatment of hypercalcemia -> fluids, fluids, fluids — In this case aggressive fluid resuscitation threw this patient into pulmonary edema. Remember that pamidronate takes 2-3 days to work.
Update: SPEP came back with M spike and increased lamda light chains highly suggestive of multiple myeloma. He is now out of the ICU and s/p bone barrow biopsy to seal the diagnosis. (To diagnose multiple myeloma you need a bone marrow biopsy looking for > 10% clonal plasma cells).
An elderly man with a history Alzheimer’s and UC s/p colectomy presents from a nursing facility with nausea and vomiting for 1 week. Found to have a calcium level of 18.
Know the DDx of Hypercalcemia
Hypercalcemia of malignancy (mets, PTHrp)
Vit D Toxicity
Milk Alkali Syndrome
Granulomatous Disease (1,25 mediated) – TB, Sarcoid
*Hyperthyroidism can also cause Hyper Ca via increased osteoclastic activity
In this case, the patient was on high doses of calcium supplements and had developed milk-alkali syndrome with a metabolic alkalosis.
EKG Findings of Hypercalcemia -> Shortened QT, Osborne Waves
Treatment: Fluids, fluids, fluids —- see how the calcium level is responding before giving Lasix;
Think about the mechanism that is causing the hypercalcemia – if due to increased osteoclastic activity give a bisphosphonate – this will take 1-2 days to work
Calcitonin: If not responding to fluids – calcitonin works quickly
This patient’s calcium level corrected over the course of a couple days with a total of 6-7 L of fluid and 2 doses of calcitonin.