allergies: no drug allergy information on file attending: chief complaint: altered mental status, hyponatremia major surgical or invasive procedure: lumbar puncture history of present illness: 33 yo f with h/o asthma, anxiety (not on medication). has had brbpr with blood on toilet paper. changed diet about 5 days prior and was reporting feeling light headed. asked to get colonoscopy by gi at , and had bowel prep in progress. also drinking lots of gatoraid. was attempting prep late last night. about 10pm, started vomiting at home. called 911, despite husband's reassurances. husband believed she was simply anxious. ems arrived at 1:30am, found to be frankful delusional, with thought of 'limb swelling'. no h/o psychiatric hospitalizations, not currently taking psychoactive medications. upon arrival, was found by ed resident to be crawling across the floor, crying out for help. serum osms very low. ? seizure by ed resident although no activity observed. found to be hyponatremic at 122 and diaphoretic. serum tox negative, no h/o ingestion. given continued confusion, attempted lp in ed, given ativan 4mg in process. could not obtain by either resident or attending. given ceftriaxone and azithromycin for meninigitis to cover infection. did get stat head ct without r/o ich. started on hypertonic saline, in consultation with pharmacy --> 350 cc of current hypertonic saline; first 8 hours correct half (not more than 10u). 45cc x next 8 hours total. then gets second half over 24 hours at 15cc/hr. also getting kcl through iv. hr 60s, sbp 95-115, rr 20s, 99% on ra. daughter is with fever (stated to be viral infection by pediatrician, f 103.2) and ms. apparently felt unwell prior to incident. past medical history: asthma anxiety g1p1 social history: lives with husband and one daughter who is an infant. no tobacco use, etoh or other medications. family history: non-contributory physical exam: 96.7, 101, 108/88, 18, 99/ra gen: appears distressed, not responsive to verbal stimuli heent: ncat, perrl, symmetric, could not assess oropharynx cv: mildly tachycardic, no m/g/r pulm: ctab anteriorly and posteriorly without w/r/r abd: soft, active bs, no palpable masses ext: wwp with 2+dp pulses bilaterally neuro: withdraws to painful stimuli, does not respond to voice, withdraws to sternal rub, toes downgoing b/l psyche: difficult to assess mental status pertinent results: admission labs: 02:00am wbc-13.1* rbc-3.98* hgb-12.2 hct-33.7* mcv-85 mch-30.7 mchc-36.2* rdw-12.6 02:00am neuts-81.9* lymphs-15.9* monos-1.8* eos-0.3 basos-0.1 02:00am plt count-250 02:00am pt-13.8* ptt-36.6* inr(pt)-1.2* 02:00am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 02:00am hcg-<5 02:00am cortisol-42.5* 02:00am tsh-3.1 02:00am osmolal-254* 02:00am caltibc-280 ferritin-57 trf-215 02:00am iron-108 02:00am lipase-22 02:00am alt(sgpt)-12 ast(sgot)-24 alk phos-55 tot bili-1.5 02:00am creat-0.6 sodium-121* potassium-3.2* 02:55am glucose-153* lactate-3.4* na+-122* k+-2.9* cl--91* tco2-19* 02:55am ph-7.38 comments-green top 03:00am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-15 bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 03:00am urine color-straw appear-clear sp -1.008 03:00am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 03:00am urine osmolal-314 03:00am urine hours-random urea n-272 creat-48 sodium-59 potassium-28 chloride-79 05:06am na+-120* k+-2.7* cl--95* 11:10am urine osmolal-504 11:10am urine hours-random urea n-222 creat-30 sodium-175 11:10am osmolal-247* 12:42pm albumin-3.9 12:42pm albumin-3.9 12:42pm glucose-110* urea n-5* sodium-122* potassium-3.9 chloride-92* total co2-20* anion gap-14 05:40pm osmolal-263* 05:40pm calcium-8.4 phosphate-2.5* magnesium-2.1 05:50pm urine osmolal-74 05:50pm urine hours-random creat-7 sodium-22 chloride-19 11:15pm urine osmolal-113 11:15pm urine hours-random creat-16 sodium-28 chloride-31 11:15pm sodium-131* . pertinent labs: 04:14am blood wbc-8.8 rbc-4.07* hgb-12.7 hct-34.2* mcv-84 mch-31.1 mchc-37.0* rdw-12.8 plt ct-232 04:14am blood plt ct-232 12:22pm blood na-139 k-3.8 04:14am blood calcium-8.9 phos-2.4* mg-2.0 12:22pm blood phos-1.6* mg-2.1 . pertinent imaging: . eeg: this is a normal routine eeg in the waking and drowsy states. there are no focal, lateralized, or epileptiform features noted. . non-contrast head ct: there is no acute intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major or minor vascular territorial infarction. the density values of the brain parenchyma are maintained. the soft tissues and osseous structures are intact. the visualized paranasal sinuses and mastoid air cells appear well aerated. impression: no acute intracranial hemorrhage. . cxr: mild increase in interstitial markings at the left base could be due to bronchitis. there is no focal area of consolidation. lungs are otherwise clear. the cardiomediastinal silhouette and hilar contours are normal. there is no pleural effusion. mild levoscoliosis is present. brief hospital course: 33 yo f with pmh reportedly of asthma and anxiety, p/w altered mental status and hyponatremia of unclear etiology. # hyponatremia: the pt presented with acute change in mental status and was found to be hyponatremic as low as 119 (lab details above). the patient was initially worked up for acute change in ms including a negative ct, lp and eeg. the patient was also given meningeal dosing for ceftriaxone, vancomycin and acyclovir, which were later dc'd. urine and serum tox were negtaive. the patient was initially hypotensive upon admission to the micu to sbp in the 80s, however it was unclear what the patients baseline sbp was in addition the patient had been given empiric dose of ativan. per report, patient was undergoing bowel prep with golytley when became acute ill and began vomiting. her hx indicated that she was drinking increased hypotonic fluids including gatorade. the patients urine osms were low at 314, but not maximally dilute, also with na > 50, so not retaining maximum na. thus the etiologies include sodium loss due to a recent change to low salt diet with excessive water replacement while others included adrenocortical insufficiency (although increased cortisol in hemolyzed sample) and siadh. the patient was initially given hypertonic saline and later changed to normal saline. the patient was water restricted and after 24hrs her mental status cleared to baseline, however she did not recall the prior days events. the patient was discharged directly from the micu to home at her baseline mental status, only complaining of mild symptoms of nausea and headache (? secondary to an lp) and able to take adquate but decreased pos. . # anemia: the patient was previously being worked-up by gi for brbpr. there was no evidence of bleeding during her admission. the pt's hct remained stable in the mid 30s. this should be followed up as an outpatient. however it should be noted that the patient appeared to become hyponatremic secondary to her go lytley dosing and thus this should be addressed if the patient is to undergo further endoscopic evaluations. . # asthma: per report. no signs of acute respiratory problems. the pt was continued on her albuterol prn medications on admission: no known outpatient medications discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for wheeze. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever or pain. 3. phenergan 25 mg tablet sig: one (1) tablet po q4:6hr prn. disp:*20 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: hyponatremia altered mental status . secondary: asthma anxiety discharge condition: good. alert and oriented x3. tolerating pos. discharge instructions: you were admitted with confusion and found to have a very low blood sodium level. this likely occurred due to your bowel prep for colonoscopy and drinking excess water and other fluids. your sodium improved with intravenous fluids and your mental status returned to baseline. a lumbar puncture was performed without evidence of meningitis. you developed a headache that was likely related to the lumbar puncture and should resolve on its own over the next 24 hours. . please take all medications as prescribed. . call your doctor or return to the ed immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, abdominal pain, sweating, fevers, chills, bleeding, or other concerning symptoms. followup instructions: call your pcp to schedule followup appointment within 2 weeks. . you should have your blood sodium checked on monday, , at your pcp's office. md Procedure: Spinal tap Incision of lung Diagnoses: Anemia, unspecified Hyposmolality and/or hyponatremia Asthma, unspecified type, unspecified Hypopotassemia Anxiety state, unspecified Hypotension, unspecified Altered mental status Electrolyte and fluid disorders not elsewhere classified Reaction to spinal or lumbar puncture Aspiration of fluid as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure