E/M Coding Rounds Case of the Week: 7/2/08

A hospital consult for hyponatremia...

REASON FOR CONSULT: Hyponatremia.

REQUESTING PHYSICIAN: Richard Y. Hayes, MD

HPI:  The patient is a pleasant 84 YOWF with a history of hypothryoidism which has been stable for several years. She also has HTN and dyslipidemia which have been well controlled on the usual medications. She underwent left hio arthroplasty two days ago. Renal consult is requested for advice and opinion regarding hyponatremia in the above clinical circumstances.


REVIEW OF SYSTEMS: CARDIOVASCULAR: Negative for chest pain, orthopnea, PND or edema. GI: Negative N/V/D.


PHYSICAL EXAMINATION:  GENERAL:  She is awake and alert, in no acute distress.  VITAL SIGNS:  Blood pressure is 1321/70, respirations 20, pulse 85.  EYES: Anicteric sclerae; no exolphthalmos or lid-lag. NECK:  No thyromegaly.  LUNGS:  Clear bilaterally with normal respiratory effort.  CARDIOVASCULAR:  Regular rate and rhythm.  ABDOMEN: Soft, NABS; no HSM.  EXTREMITIES:  Show no peripheral edema. PSYCH: A&OX4; appropriate affect 

LABORATORY INFORMATION:  Shows a sodium 127, BUN 24, creatiinine 0.7, potassium 4.1, HGB 14.1.

IMPRESSION:

1. Mild asymptomatic euvolemic hyonatremia presumably due to transient SIADH associated with post-op pain.

PLAN:

1. Urine/serum osmolality
2. Urine creatinine/sodium to calculate FeNa.
3. TSH
4. Hold HCTZ
5. 1500 cc fluid restriction
6. Renal profile in a.m.