DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hyponatremia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with a history of metastatic pancreatic cancer. He is in rehab with generalized weakness. He has liver metastasis and is status post chemotherapy with cisplatin, gemcitabine, and dexamethasone. He has a history of COPD and has cognitive impairment that is felt to be multifactorial but pending is followup head CT and psychiatry evaluation. Chart suggests that he has nausea. Unfortunately, the patient would only state that he feels “good.” He would not answer questions or participate in exam. He remains curled up. Chart also suggests that he has a history of hematuria, and urine culture is pending per the chart.
PAST MEDICAL HISTORY: Significant for hypertension, anxiety, depression, COPD, and there is a note on prior history and physical that he is disabled. History of subtotal colectomy and anastomosis with J tube placement, liver biopsy, peptic ulcer disease, pancreatic cancer with hepatic metastasis.
ALLERGIES: NKDA.
MEDICATIONS: Reglan 5 mg q.a.c. and at bedtime, Norvasc 5 mg b.i.d., Diovan 160 mg daily, Paxil 20 mg daily, Prevacid 30 mg daily, Lopressor 25 mg daily, heparin 5000 units subcutaneously q.12 h., Toprol-XL 25 mg p.o. b.i.d. was stopped, Ativan 1 mg q.6 h. p.r.n., codeine 30 mg q. 3-4 h. p.r.n., Nitrostat 0.4 mg sublingual daily, Compazine 10 mg q.6 h. p.r.n., Tylenol 650 mg q.4 h. p.r.n., Mylanta 30 mL p.r.n., Dulcolax suppository, Colace 100 mg p.o. p.r.n., Senokot 17.2 mg p.r.n., Ambien 5 mg at bedtime sleep, saline enema rectally p.r.n. constipation, and potassium chloride was given 20 mEq x1.
SOCIAL HISTORY: As above. Note that the patient is disabled. The patient was a prior smoker.
FAMILY HISTORY: Unable to obtain from the patient.
REVIEW OF SYSTEMS: As above. The patient is currently labile and states nothing more than “good.” He does not respond to further questions or assist in exam.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: We spoke with the patient’s nurses who state that the patient just does not talk.
VITAL SIGNS: Temperature 97.6, pulse 78, respirations 22, blood pressure 110/58 from 146/86, saturation 96%. Intake chart shows 1175 in and 1400 out.
HEENT: The patient appears chronically ill, thin, pale, and he is curled up in a ball and not helpful with exam. Normocephalic.
NECK: Without JVD.
CHEST: Clear.
HEART: Regular rate and rhythm without gallop or rub.
ABDOMEN: Soft, but exam is very limited.
BACK: Without CVA tenderness.
EXTREMITIES: No edema.
RADIOLOGIC STUDIES: Head CT has returned stable, no acute abnormality.
LABORATORY DATA: Sodium 128, potassium 3.6, chloride 90, bicarbonate 32, anion gap 6, glucose 116, BUN 15, creatinine 0.6, estimated GFR greater than 60, calcium 9.1, phosphorous 3.6, white count 15.2, hemoglobin 13.2, and platelets 372,000. BNP only 54. Fecal occult blood negative. C. diff negative. Urinalysis: Large blood, trace leukocyte esterase, full field red cells, and 3 white cells. Urine random creatinine 47, random urine sodium 58, random urine osmolality 409, p.m. cortisol was at 35.2. Urine culture was no growth. TSH is within normal limits.
IMPRESSION:
1. Hyponatremia.
2. Hypertension history.
3. Chronic obstructive pulmonary disease.
4. Metastatic pancreatic cancer with liver metastasis, status post cisplatin chemotherapy and other agents.
5. Hematuria.
DISCUSSION AND PLAN: We suspect that the patient has SIADH secondary to nausea and pancreatic cancer. Urine osmolality was inappropriately high. Rechecking of the urine osmolality, serum osmolality, and urine sodium is pending. Also pending urinalysis, urine osmolality, uric acid, urine sodium, urine creatinine and urine protein. He has free water flushes going with his tube feedings. Nursing reports she is giving free water but chart suggests he has 0.9 ordered. We would agree with 0.9 as a recommendation here. Consider alternatives to the class of agents for depression as SSRI inhibitors can contribute to SIADH and hyponatremia. Cisplatin can contribute to polyuria, hence we would follow I’s and O’s and daily weights. If in fact he is polyuric, he may have further salt and volume loss there. If he is not polyuric, we would recommend backing off on 0.9 and following up the chemistries. In terms of his hematuria, consider Urology evaluation, if urine culture continues to be negative and if there is no resolution. In light of his metastatic cancer however, we are not sure how aggressive you want to be for a full workup for hematuria.
Thank you very much for asking our opinion in consultation.
