Other disorders of neurohypophysis Allergic rhinitis cause unspecified Unspecified acquired hypothyroidism Cough Anemia unspecified Pure hypercholesterolemia Unspecified essential hypertension Diverticulosis of colon (without mention of hemorrhage) Osteoporosis unspecified Memory loss
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Aspirin
 
Attending: ___.
 
Chief Complaint:
Hyponatremia and Lethargy 
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
History of Present Illness: The patient is an ___ y/o F with PMHx 
of HTN, HLD, hypothyroidism, and hyponatremia, who is presenting 
to the emergency department with hyponatremia. Per report, the 
patient had been seen by her PCP yesterday, where lab work was 
performed that showed a sodium of 120. She was sent to the ED 
for futher evaluation. Per ED report, the patient has a history 
of hyponatremia for which she takes salt tablets. However, she 
has been experiencing generalized malaise over the past week and 
has missed some of these tablets as a results. Her family also 
feels that she has recently been somewhat lethargic. 
.  
In the ED, initial vs were: T 98.0 P 75 BP 170/64 RR 16 O2 sat 
100%. Patient was given 1L NS.  
.  
On arrival to the ICU, the patient's VS were BP: 203/67 P: 85 R: 
16 O2: 96%RA. She endorsed feeling lethargic and under the 
weather since ___. During this time, she has had some 
generalized body aches and decreased PO intake. She also 
endorsed ___ weeks of non-productive cough. She also complained 
of some mild headaches and some mild intermittent shortness of 
breath. Her husband is sick with similar symptoms.
.  
Review of systems:  
(+) Per HPI  
(-) Denies fever, chills. Denies chest pain, chest pressure, 
palpitations, or weakness. Denies nausea, vomiting, diarrhea, 
constipation, abdominal pain, or changes in bowel habits. Denies 
dysuria, frequency, or urgency. Denies arthralgias or myalgias. 
Denies focal numbness, weakness, or tingling.  

 
Past Medical History:
HYPERTENSION
HYPOTHYROIDISM
HYPERCHOLESTEROLEMIA
HYPONATREMIA, suspected SIADH
DIVERTICULOSIS
LOW BACK PAIN, hx spinal stenosis
CATARACTS 
ALLERGIC RHINITIS
OSTEOPOROSIS
GLAUCOMA
ECZEMA
GASTRIC ULCER
SCOLIOSIS
MEMORY LOSS
HEMORRHOIDS  
s/p TAH/BSO for postmenopausal bleeding
BLADDER PROLAPSE s/p suspension

 
Social History:
___
Family History:
Non-contributory.

 
Physical Exam:
Vitals: BP: 203/67 P: 85 R: 16 O2: 96%RA 
General: Alert, oriented to person and place  
HEENT: Sclera anicteric, MMM, oropharynx clear  
Neck: supple, JVP not elevated, no LAD  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur 
heard throughout
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
Ext: pneumoboots in place, no ___ edema appreciated
Neuro: Moves all 4 extremities spontaneously. Non-focal 
neurologic exam.  

On Discharge:
Mental status improved to oriented x3 and much more alert and 
interactive.
 
Pertinent Results:
Admission:
___ 04:00PM BLOOD WBC-9.3 RBC-4.73 Hgb-14.3 Hct-40.6 MCV-86 
MCH-30.2 MCHC-35.2* RDW-13.3 Plt ___
___ 04:00PM BLOOD UreaN-9 Creat-0.6 Na-120* K-4.1 Cl-85* 
HCO3-31 AnGap-8

Discharge:
___ 11:09AM BLOOD WBC-8.6 RBC-3.81* Hgb-11.7* Hct-32.9* 
MCV-87 MCH-30.8 MCHC-35.6* RDW-13.5 Plt ___
___ 07:23AM BLOOD Glucose-101* UreaN-19 Creat-0.5 Na-128* 
K-3.6 Cl-96 HCO3-22 AnGap-14
___ 07:23AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8

Miscellaneous:
___ 07:23AM BLOOD ___ PTT-24.3 ___
___ 04:00PM BLOOD ALT-30
___ 04:00PM BLOOD Triglyc-75 HDL-59 CHOL/HD-2.4 LDLcalc-70 
LDLmeas-66
___ 12:20AM BLOOD TSH-4.5*
___ 10:12AM BLOOD Free T4-1.4

CHEST (PA & LAT) Study Date of ___ 3:39 ___ 
REASON FOR EXAM: Cough, weakness and anorexia. 
  
Comparison is made with prior study ___. 
  
There is mild cardiomegaly. The aorta is elongated. There is 
probably a 
hiatal hernia. The lungs are hyperinflated, the hemidiaphragms 
are flattened suggesting COPD. Bibasilar opacities are 
consistent with atelectasis, left greater than right. 

 
Brief Hospital Course:
___ y/o F with PMHx of HTN, HLD, hypothyroidism, and 
hyponatremia, who is admitted with hyponatremia in the setting 
of lethargy and decreased PO intake.

# Hyponatremia: Hypovolemic hyponatremia vs. SIADH. Likely a 
combination of the two with suspected SIADH per PCP notes as 
well as poor PO intake lately. She was given 3L of NS. Her 
sodium improved from 120 to 128 over two days and her symptoms 
and lethargy improved. She was continued on her home salt tabs. 
To ensure close monitoring she was discharged ___ with plan for 
a lab draw on ___ to evaluate for interval change of her 
sodium.
Follow-up:
- Sodium on ___ to be faxed to Dr. ___ at 
___

# Anemia: After fluid resuscitation, her HCT dropped to 33.3. On 
recheck it was stable at 32.9. She was discharged with 
outpatient lab work to be checked on ___ to evaluate for 
change.
Follow-up:
- Hematocrit on ___ to be faxed to Dr. ___ at 
___ 

# Cough/Myalgias/Lethargy: Likely viral illness. She was 
afebrile with no obvious pneumonia on CXR. Her flu swab had 
insufficient cells so a culture was added on. It was pending at 
the time of discharge.
Follow-up:
- Flu culture

# Hypertension: Stable throughout her course. She was continued 
on her home valsartan dose of 320mg.

# Hypothyroidism: Her TSH was checked (4.5) and T4 was normal. 
She was continued on her home levothyroxine dose of 75mcg.

# Allergic Rhinitis: Continued fluticasone nasal spray

# Transition issues: She was discharged with a plan to have 
sodium and hematocrit checked on ___ with results to be 
faxed to Dr. ___.
 
Medications on Admission:
Fluticasone Nasal Spray 50 mcg, 2 sprays each nostril daily
Levothyroxine 75 mcg daily
Nystatin Powder
Nystatin-Triamcinolone Cream
Simvastatin 40 mg daily
Sodium Chloride Tabs 1 gram daily
Valsartan 320 mg daily
Aspirin EC 81 mg daily
B Complex Vitamins
Calcium Carbonate
Calcium Citrate-Vitamin D2
Docusate Sodium 100 mg daily
Loratadine 10 mg daily

 
Discharge Medications:
1. Outpatient Lab Work
Please check sodium and hematocrit ___. Please fax results 
to Dr. ___ at ___: ___ 
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) 
Spray Nasal DAILY (Daily).  
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
5. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
6. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 
 
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
8. nystatin-triamcinolone 100,000-0.1 unit/g-% Cream Sig: One 
(1) appl Topical twice a day as needed for Rash.  
9. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.  
10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) 
Tablet PO once a day.  
11. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) 
Tablet PO once a day.  
12. B Complex     Tablet Extended Release Sig: One (1) Tablet 
Extended Release PO once a day.  
13. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: 
Hyponatremia

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
Ms. ___, 

It was a pleasure taking part in your care. You were admitted to 
___ with increased lethargy and generally feeling unwell. You 
were found to have a low salt level in your blood which can 
cause these symptoms. We gave your IV fluids, and limited the 
amount you should drink as well as put you back on your salt 
tablets. 

Your salt level increased and you felt much improved. 

We did not make any changes to your medications.

Please take your medications as prescribed.

Please have blood work drawn on ___ to be sent to Dr. 
___.
 
Followup Instructions:
___

{'Hyponatremia': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Lethargy': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Generalized malaise': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Body aches': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Decreased PO intake': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Non-productive cough': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Mild headaches': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension'], 'Mild intermittent shortness of breath': ['Other disorders of neurohypophysis', 'Unspecified acquired hypothyroidism', 'Pure hypercholesterolemia', 'Unspecified essential hypertension']}