So next patient kathleen golden '5 342 08/07/1976 year old lady presented complaint anxiety, confusion observations respiratory rate 18 oxygen saturation 99% on air pulse 69 blood pressure a 114 over 59 temperature 36.5 alert current repeat medications in dapamide 1.5 mg modified release once each morning candesartan 32 mg 1 tablet once each day past medical history hypertension nondiabetic hyperglycemia total abdominal hysterectomy 1994 investigations beta and folate normal sodium 114 previously has been low at a 125 in august and was normal in june 2025 at a 136 potassium 3.1 ferritin 151 tsh 1.14 calcium normal albumin normal lfts normal glucose 5.9 cholesterol normal crp less than 1 urine normal magnesium normal inr 1 venous blood gas ph 7.47 with low chloride low ionized calcium low potassium and low sodium so plan add on serum osmolality urinary sodium urinary osmolality in power monitoring add on tsh 9am cortisol tomorrow morning add serum lipids and myeloma screen I'm doctor miller I'm 1 of the medical registrars nice to meet you sorry you've spent an evening in a chair how are you feeling I'm tired tired really of course have you because always I always take it since 7 okay fine I was gonna say stop taking it but that's alright if you've already done it don't worry thank you it's okay goodness there's so many options isn't there taking a pic I guess that looks very comfortable why don't you sit there yeah how are you shattered shattered yeah what brought you into hospital well I felt I didn't feel well at school and I felt difficult to describe I just felt agitated and restless mhmm and then it was a long time ago mhmm of course yeah you must be so sleep deprived of me yeah your so yeah so you've your your gp found low sodium levels in your blood test yeah and you went to see them and you went to see them I I guess because you both had these symptoms of feeling agitated and restless and not oh that yeah that was very good and when and when did you first notice those symptoms gosh it certainly got worse yesterday morning worse yesterday morning okay yeah alright so it's a relatively short history of that yeah any other symptoms at all shortness of breath or cough cold symptoms you got a cough yeah when did that start well I've always had a winter cough okay because I do get winter cough because of having whooping cough as a child mhmm but lately I've been waking up in the night coughing mhmm and that's unlikely it's it's it's annoying a bit early yeah fine and bring anything up no no no it's just a dry cough at night okay yeah but not pleasant any trouble with the waterworks it's I'm not peeing like I used to I'll I'll put that down to the what is it indapamide indapamide yeah which I think you know just does affect your pee yeah sorry that's okay no it's fine so and I've been I'm asking about symptoms that have changed over the last couple of weeks it doesn't sound like your urine's changed over the last couple of weeks not really because I think it's the fact I think it's the medication it's just this you know feeling just feeling unwell now I'd say and how about your weight have you lost weight at all lately I haven't been sleeping haven't been sleeping okay I haven't been eating very well either so it's like it's all got a it's all got a bit silly and how about your weight I used to take it every week I haven't taken it but I think it's probably gone down I don't know I don't know have you had to estimate how much weight do you think you'd lost I don't know that's okay don't worry around 9 stones something around that mhmm fair enough I have no idea at the minute okay alright medical problems in the past I've had a read sounds like you just have high blood pressure for which you're taking dapamide and candesartan you had a previous hysterectomy in the past but nothing much a ago long good that's me yeah that was in the nineties yeah yeah but there was nothing else I don't think so do you take any over the counter medicines any herbal treatments anything additional to the indapamide and the candesartan no no because I'm very wary of doing that okay that's a good not a good idea fair enough and are you allergic to anything pollen pollen okay as you know it's yeah yeah okay but no medicines alright fine who lives at home with you I'm on my own my son's row down from kent yesterday which is good of him that's good so he's in buck you're in the house in buckwhasley at the moment okay right and that's where you live in buckwhasley yeah lovely that's nice and what did you do for a living I retired early mhmm but I I was in various things worked in trained as an enrolled nurse couldn't say how many years ago when they still had enrolled nurses okay worked in toujeo for a couple of years and then went to work at rowcroft and I was there for about 13 years wow the nurse yeah so I sort of set up a complimentary health service amazing seems a long time ago yeah okay I think I've just got very low as well and it and it's like tell me about that how long have you been feeling low for well my neighbors noticed something about about a month 6 weeks ago they said oh what's your medication and I said well you know I don't know you've got it's easy to say that isn't it yeah it is but I've had problems at home with communication outlets like bt and in terms of bills no no no no it's it's because now my heating I couldn't oh it sounds ridiculous you couldn't switch heating on well not not I couldn't I've got I've done the timer before I just couldn't get the timer right and you know when you try something because the more you try it the worse the worse it gets it won't get easier yeah never supposed to change to this digital thing you know the digital broadband thing digital phone thing yeah I think they're doing that aren't they I've heard I've seen some adverts about it so some trouble with that and anything else that's that's stressing you out just the fact I'm not I feel a bit wobbly at times when I go out walking feel a bit wobbly mhmm of course now whether that's because I feel anxious I have no idea it's like oh gosh mhmm I've just got in a bit of a pickle do you know what mean it's like it's like mhmm okay things just haven't been you just haven't your mind just hasn't been working fantastically over the last few weeks is that fair to say overdrive mhmm you've been very anxious that's the problem it's just been working in overdrive okay and has anyone explained the results of your tests or anything like that to you has anyone explained the results of your blood test that you have with your gp I in had sodium levels I had blood taken out and they were going to come back and take it some 2 hours later they didn't that was yesterday yeah sorry it's sitting you're sitting in there it's sitting in there yeah so your sodium levels are very low yeah they should normally be a 135 yeah and yours are a 114 right which is very low yeah and that can affect the functioning of your mind yeah need sodium for all of your cells yes of course and when you're and when and the brain cells are very sensitive to a low sodium level so I suspect that's why you've been feeling poorly and not yourself well it's added to it hasn't it certainly but you've had low sodium a little bit of low sodium since august really it's not been as severe as this but your blood tests in august did show a slightly low sodium as well but then it was normal in june so something's changed over that time with your sodium and that seems to correlate temporally with your symptoms in terms of when they started you make it sound really no you don't make it sound trivial it sounds really trivial when you say it sorry and it's like I don't mean to trivialize it it's not to me yeah I hope you don't feel trivialized no no your sodium levels are very low and that's why you're having these symptoms yeah and that's a dangerous thing and it's important you're in hospital yeah I certainly don't want to trivialize it you're very ill with these sodium levels right they can be very dangerous they can be life threatening people can have seizures with these low sodium levels it's a very good good job you're here is my. I'm not trivialising things we're looking so after you very it's important that you're here what's also important is to send off some more tests I've added a big battery of tests onto the blood tests you've had already sent to the laboratory and you should have some blood tests taken at 09:00 this morning just to look for underlying causes of this low sodium level sometimes problems with the thyroid gland the adrenal glands and yes of course other difficult other problems with the hormonal system which I'll test for can cause these low sodium levels have you been drinking very much lately water or anything else I've been keeping hydrated because obviously I know that's important how much water do you drink do you make yourself drink yes when you're not thirsty well yes I drink I just put the grass there and I just drink it as and when I do you drink liters and liters and liters of water a day oh god no no good you don't drink 4 l of water a day or something like that some people no walk around with these big bottles and drink and drink and drink but that's not you no no that's fine alright and you're weeing okay you said you'd had some change with the indapamide changes on the indapamide certainly mhmm but you're but you are still passing water yeah yeah have you noticed any swelling in your ankles or anything like that like you're retaining amlodipine and they cause my I see yeah fine both the candesartan and the indapamide can drop the sodium levels as well when did you start the indapamide goodness me I think it's not quite 2 months ago okay fine I said I took it this morning simply because I'm so used to no it's okay 07:00 so that makes perfect sense in terms of your blood tests as well that your sodium has been dropping for the last 2 months yeah essentially and I suspect that's that's probably why the in because of the indapamide oh I'll get you a drip with some sodium in it to bring your sodium up gently and gradually I'll ask them to check your sodium twice a day with some blood tests to make sure that we're not bringing it up too quickly because we need to bring it up in a nice safe manner I'll stop the indapamide and we'll keep a really close eye on things that's okay but we won't have any more that's fine it's not your fault don't worry that's fine I'd suggest stopping it certainly during this admission and probably forever and switch to something different something that works with your sodium levels a bit better but would you be able to prescribe that yeah we'll sort that all out when you get out of here we can keep an eye on your blood pressure while you're in and if your blood pressure's high without the indapamide we can switch you to something else yeah that's what I would it's really strange situation where I just feel everything's you know just yeah horrible horrible feeling must be your mind just not feeling the same as it was not functioning exactly and as I say that's all because of those sodium levels that are very low right mhmm do you mind if I look at your hands and listen to your chest is that okay yeah thank you I'll just wash my hands thank you do you drink or smoke no no nothing like that you're a clean living kind of person that's good me too that's good to be born and what is your son do he works in is he hands drove it yesterday from kent can I have a look at your hands is that okay thank you yeah go on that's gone numb since I've been sitting but I think it must be my position just this bit of your hand yeah it's not this bit and your little finger mhmm from resting your elbow down irritates the ulnar nerve which supplies that part of your hand you drove down from kent you said and went to ct for a living kent this morning he works he works independently in in a minute so he's worked for age he played for years and years and then another longevity charity okay oh great he's done some interesting things oh lovely quick listen to your heart soak if were to sit forward I can have a quick listen to your back please yeah thank you very much can I pop this up just to I don't need to take it all up that's probably fine just big breaths whenever you're ready and out and again actually I might pop up here that's alright 1 more time that's fine thank you can I have a look at your legs okay thanks and these compression stockings are they is it because your legs had been swelling or are they it was it was the only thing I could find handy when I came home I see that's fine that's alright that's good I'm glad your legs haven't been swelling up that's fine thank you great so as I say I'll sort those blood tests out we'll give you a slow drip of some sodium we'll stop the indapamide moving forward rare to take it I guess we've got your don't worry it's not your fault don't worry sometimes people can have chest infections which can drive the sodium down more so I suggest we x-ray your chest to make sure that you haven't got a pneumonia causing a bit of this as well so we'll get that sorted while you're here mhmm and then we'll keep an eye on your sodium very closely and bring it up in a safe manner and then over the next day or so I'd hope it will be in a nice safe range yeah but it may be it's sunday morning now I think yep so it may be well you're on yeah it may be monday or tuesday before you're able to get out of hospital safely with the safe sodium level okay is alright that because we try to be at about 8 millimoles a day and yours gonna it's gonna take at least 2 days to bring it up to a safe level above a 100 and above around a 130 from a 114 if that makes sense yeah so if we're exactly on target it'll be tuesday does your son want me to give him a call on that to let him know what's going on or oculus is that okay yeah fine I'm happy to update him if he wants with you all of course so he's probably shattered he's probably shattered as well yeah you must be well I'm sorry about the bed situation it's crap I know 1 likes you can't help that unfortunately no but I'm still still sorry we'll we'll get you a bed on our medical unit when we can and and look after you there okay any questions or anything I've forgotten I don't think so 1 thing I've forgotten is to ask you about resuscitation we speak to everyone that comes into hospital about resuscitation I from my perspective we should do everything to resuscitate you if things were to go if things weren't to improve I don't anticipate that happening but in I have to ask everyone about it just to make sure you don't have any strong views about it are you okay with that okay lovely I'm glad that's good should I pop you back to your lovely chair then at least it's a bit darker than this blinding room you'll have some notes in here and I'll ask them to give you a little bit of fluids gonna very curious just keep some of these tests down yeah well actually this doesn't happen I'm gonna go see the cts behind okay yeah thank you alright ma'am can I leave your hand sometimes the low sodium can make you a little bit unsteady on your feet as well I don't know if you've noticed that yeah some people more than others hello hello doctor are you the medic I am the medical registrars sorry but I have patients who need they are taking a medication to put it out there yeah are they have they been so impression is hyponatremia secondary to indapamide plan stop indapamide hold candesartan monitor blood pressure as inpatient iv fluids aiming for sodium of increase sodium increase of 8 millimoles per liter in 24 hour? Bd sodium measurements while under a 120 input output monitoring