Physician's Assistant

Refined clerking Sun 28 September 2025 06:34

Last Modified: 190 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Anxiety and confusion

History of Presenting Complaint:
This 76-year-old lady presented with a short history of feeling agitated and restless, which worsened yesterday morning. Slightly repetitive and muddled. Neighbours noticed changes approximately 6 weeks ago.

She has also developed a dry nocturnal cough. She reports poor sleep and reduced appetite over recent weeks, with possible weight loss though unable to quantify. She feels "wobbly" when walking and describes her mind as being "in overdrive" with increased anxiety.

No night sweats, pain, CIBH.

Her GP found low sodium levels on blood testing, with current level at 114 mmol/L compared to 125 mmol/L in August and normal levels of 136 mmol/L in June 2025.

Took indapamide this morning in chairs - no prescription

Past Medical History:
 Hypertension
 Non-diabetic hyperglycaemia 
 Total abdominal hysterectomy (1994)

Drug History:
 Indapamide 1.5mg MR PO OD (started approximately 6 weeks ago)
 Candesartan 32mg PO OD

Allergy History:
 Pollen (hay fever)
 NKDA

Social History:
Lives alone. Son travelled from Kent to support her.
Retired, previously worked as nurse including 13 years at Rowcroft
Non-smoker, no alcohol consumption.

On Examination:
General Appearance: Alert, tired. Spent the night in chairs.
Observations: RR 18, O2 sats 99% on air, HR 69, BP 114/59, Temp 36.5°C
 Cardiovascular: Heart sounds normal
 Respiratory: Clear chest on auscultation
 Other: No peripheral oedema

Investigations:
 Sodium 114 (previously 125 in August, 136 in June 2025)
 Potassium 3.1
 Ferritin 151
 TSH 1.14
 Glucose 5.9
 CRP <1
 Calcium normal
 Albumin normal
 LFTs normal
 Cholesterol normal
 Magnesium normal
 INR 1.0
 B12 and folate normal
 Urine normal
 VBG: pH 7.47 with low chloride, low ionised calcium, low potassium, low sodium

Impression:
Severe hyponatraemia (114 mmol/L) secondary to indapamide

Management Plan:
1. Stop indapamide, hold candesartan
2. IV fluid therapy with sodium replacement aiming for 8 mmol/L increase per 24 hours
3. BD sodium monitoring while sodium <120 mmol/L
4. Input/output monitoring
5. Additional investigations: serum osmolality, urinary sodium, urinary osmolality, 9am cortisol [/]
6. Chest X-ray
7. Monitor blood pressure as inpatient, consider alternative antihypertensive if needed
8. Medical ward admission, estimated 2-3 day stay until sodium safe
9. TEP: Full escalation
10. 3 days of PO K replacement

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Refined clerking Sun 28 September 2025 06:34

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