Instructions
You are a medical student on placement in the emergency department. Paraskevi Galanis, 82, has been brought in by her husband after two falls at home this week; he says she has been muddled for four days.
Interpret the results provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis
- You do not need to take a history or examine the patient
- You do not need to outline a management plan
- The examiner will ask you one question at the end
Husband's account
Fell in the bathroom on Tuesday and in the kitchen this morning; he does not think she hit her head. Muddled and unsteady for four days, forgetting what was said. No vomiting, diarrhoea, fits or headache. Drinks 8 to 10 cups of tea a day, as she always has; eating as usual.
Current medicines
Indapamide 1.5 mg modified release each morning (started by her GP three weeks ago for blood pressure); amlodipine 5 mg daily (4 years); sertraline 50 mg daily (2 years, for low mood); atorvastatin 20 mg at night
ED doctor's examination
Oriented to person but not to date or place; GCS 14. No focal neurological signs. Dry mucous membranes; no oedema; chest clear. Bruised left hip with full, pain-free movement; pelvic X-ray shows no fracture.
Bloods (ED, today)
| Item | Value | Reference range |
|---|---|---|
| Sodium | 118 mmol/L | 135-145 mmol/L |
| Potassium | 3.0 mmol/L | 3.5-5.2 mmol/L |
| Chloride | 82 mmol/L | 95-110 mmol/L |
| Bicarbonate | 29 mmol/L | 22-32 mmol/L |
| Urea | 7.9 mmol/L | 3.0-8.0 mmol/L |
| Creatinine | 84 umol/L | 45-90 umol/L |
| Glucose (random) | 5.6 mmol/L | 3.0-7.7 mmol/L |
| Serum osmolality (measured) | 252 mOsm/kg | 275-295 mOsm/kg |
| TSH | 1.9 mIU/L | 0.4-4.0 mIU/L |
| Cortisol (9 am) | 410 nmol/L | 140-540 nmol/L |
Spot urine (ED, today, before any fluids)
| Item | Value | Reference range |
|---|---|---|
| Urine osmolality | 390 mOsm/kg | - |
| Urine sodium | 48 mmol/L | - |