Testing

Question:

A 58-year-old man with a 45-pack-year smoking history comes to the clinic due to a persistent cough. The cough started about 3 months ago and is distinctly worse than his usual smoker's cough. During this period, he had episodes of hemoptysis and lost 9.1 kg (20 lb). He has had no nausea, vomiting, fever, chills, night sweats, pruritus, seizures, or gait abnormalities. Temperature is 36.9 C (98.4 F), blood pressure is 134/85 mm Hg without an orthostatic drop, and pulse is 76/min. Temporal wasting is evident. The mucous membranes are moist, and the neck is supple without lymphadenopathy. Heart and breath sounds are normal. The abdomen is soft and nontender. No peripheral edema is present. The patient is oriented to time, place, and person. Pupils are equal and reactive, and no nystagmus is elicited. Neurologic examination, including gait, is normal. Laboratory results are as follows:

Which of the following is the best initial treatment for this patient?

Answers:

A. Intravenous albumin

Your reply:

B. Demeclocycline

Correct answer:

C. Fluid restriction

D. Use of hypertonic saline

E. Lactated Ringer solution

F. No additional intervention

G. Normal saline

Explanation:

Choice A. Intravenous albumin may provide some benefit in the management of hypervolemic hyponatremia in patients with cirrhosis. However, it is not useful in the management of SIADH, even in those who are hypoalbuminemic, such as this patient.

Choice B. Demeclocycline acts at the level of the renal collecting tubule to decrease responsiveness to antidiuretic hormone. It is sometimes used in the treatment of SIADH; however, it can be nephrotoxic and should be considered only if fluid restriction and high salt intake fail to correct the hyponatremia.

Explanation

Educational objective: Hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion is a common complication of small cell lung cancer. Fluid restriction is the initial treatment of choice in asymptomatic or mildly symptomatic patients.

Choice D. Use of hypertonic saline can be dangerous due to the risk of sodium overcorrection; it should be reserved for severe symptomatic hyponatremia (eg, seizures, coma, profound confusion) or cases of hyponatremia that are resistant to other treatment.

Choice E and G. Both lactated Ringer solution and normal saline are forms of isotonic fluid. Infusion of isotonic fluid is appropriate for hypovolemic patients; however, it often results in net free water retention and worsening of hyponatremia in those with SIADH.

Choice F. Further intervention is required as this patient's hyponatremia is likely to worsen without fluid restriction.

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