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Below is the clinical summary of a patient who has had recurrent episodes of hyponatraemia that was attributed to inappropriate ADH but I am unconvinced by that explanation. Urea and creatinine concentrations have remained very constant from before the first episode of hyponatraemia in June 06 since when there have been two other episodes. Given the recent low urine sodium despite diuretics (for oliguria) and urine osmolality < serum osmolality what do members share my concern over fluid restriction? Any comments/thoughts appreciated. Trevor Tickner, Norwich A brief summary. 66 year old female Traumatic spinal cord injury in a RTA in 1961 ( 45yrs ago)- resultant T2 paraplegia with left sided sympathetic chain damage causing a left horners syndrome. Injury was a C6/7 fracture dislocation- managed conservatively. No head injury documented Other medical History: 1. Neurogenic bladder on long term suprapubic catheter (>20 yrs)- with shrunken bladder and detrusor hyperactivity. No kidney damage on ultrasound. 2. Type 2 DM on Metformin 1gm bd and Gliclazide 80mg od 3. Hypercholesterolaemia on Atorvastatin 4. Osteoporosis with lower limb fractures. Intolerant of Bisphosphonates Mobile using electric wheelchair. Active in art and gardening. Well until June 06 Current Medication: Demeclocycline 300mg bd Atorvastatin 10 mg on Tinzaparin 0.7ml od (Therapeutic heparin as warfarin caused INR 0f 14) Multivitamin OHA's stopped on 17/1/06 because of anorexia & low BM's Domperidone 10mgs tds for persistent nausea Time line Symptoms Signs Investigations Mx 13/6/06 Nausea for 1 week. Nil- no evidence of fluid retention Na 113 Normal Renal & Liver function (RFT& LFT). Ultrasound kidneys normal. Short Synacthen test (SST) negative, Thyroid(TFT) Function Normal Urine osmolality 494 Serum osmolality 241 Urine Sodium 55/44 Dothiepin stopped (Been on this for > 10yrs) Fluid restriction + Demeclocycline 14/6/06 Short synacthen cortisol 30 min sample 1269 nmol/l Serum osmo 241 Na 115 K 4.5 Alb 32 Urine osmo 494 5/8/06 Coughing epidode with O2 desaturation to 89%, Tachypnoea B/L chest crackles, respiratory distress. CXR Rx for chest infection with Amoxicillin 8/8/06 Persistent SOB on lying down Persistent B/L crackes Echo : Severe Pulmonary Hypertension. PA pressure 77mmhg + (r) Atrial pressure, Dilated impaired (r) ventricle. Good LV function Had a CTPA- no evidence of thromboembolic disease. Referred to Respiratory team by Cardiologist. August 06 Persistent nausea Nil new Na continues to fall off Demeclocycline 23/8/06 Na is 124 Demeclocycline restarted 1/9/06 Weight loss of 8kgs since June Overnight oximetry- overnight hypoxaemia with O2 saturation <90, 30% of the night. Referred to specialist hosp for respiratory Inv: 1. Overnight sleep studies mildly suggetsive of central sleep apnoea but no indication for ventilation October- November 2006 Occasional episodic SOB V/Q: Suggestive of distal thromboembolic disease- ventilation part could not be done as pt unable to do December 06 Tiredness Nil new Na 130 on 12/12/06. K 5.2 Normal RFT, LFT, CRP and ESR 19 22/12/06 Specialist hosp adv anticoagulation Warfarin started January 07 Episodic SOB, General decline. Cognitive decline- MMSE 16/30 Na 129, K 5.2 on 2/1/07 Short Synacthen Negative 9/1/07 Continues to be confused, anorexic , tired Na 121 15/1/07 Tachypnoea, confused, oliguric . Urine output < 100ml Persistent B/L crackles- except right apex Na 120, K 5.8, Bicarb 32 Normal RFT INR 13.18. Rechecked INR 14.78. Mild LFT derangement with ALT -76, GGT 23 Had had one dose of 100mg of spirinolactone on 14/1/07 RX . Vitamin K Frusemide to cause diuresis- 40mg Stop sprinolactone 16/1/07 Still confused Urine output 500-600ml last 24 hrs. Now again low Persistent B/L crackles Na 119, K 5.3 Normal RFT Serum osmolality 245 Urine osmolality 225 Urine Na < 5 Frusemide 40mg repeated 17/1/07 Still confused, SOB Persistent crackles Urine output post frusemide 1L INR post Vitamin k 1.39 Bm's low Urgent echo: As before, good LV function CXR: No consolidation Oral hypoglycaemics stopped ABG: ype 2 respiratory failure Fluid restriction 750ml + Demeclocycline 22/1/07 Still SOB and confused Improving B/L crackeles Improving Urine output- 1L over 24 hrs Na 128, K 4.5 23/1: Na 130, K 4.5 MRI: No brain lesion. Small 7mm cyst in posterior pituitary likely aracnoid or Rathke's cleft cyst displacing anterior pituitary forward 23/1/07 Continues on 24% oxygen Anterior pituitary funcion: WNL LH: 2.6 FSH 45 TSH 1.29 Posterior function: Prolactin 1621 Continues on Demeclocycline 24/1/07 Na 132, K 4.1 Bicarb 33. Normal RFT, LFT Chol 2.6, TG 0.58, Urate 220 (0-450) serum osmolality 264 urine osmolality 236 Na 18 K 18 Continues on Demeclocycline Other avenues pursued: CT abo/pelvis request to r/o malignancy denied Not fit for investigation of persistent nausea by endoscopy Not fit for cystoscopic inv of bladder No evidence of pulmonary malignancy on CXR and CTPA (non smoker) This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the originator of the message. This footer also confirms that this email message has been scanned for the presence of computer viruses but this should not be relied upon as a guarantee that the contents are virus free. 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