A 60-Year-Old Woman With New Seizures

Robert M. Centor, MD


September 19, 2006

This series of cases offers an opportunity for you to work through the diagnostic process, determining what tests to order and which questions to ask. A discussion link is provided below to facilitate that process.

The patient is a 60-year-old woman, with known paranoid schizophrenia and major depressive disorder, who presented to the emergency room (ER) after having a seizure at home. In the ER she had another witnessed seizure. She cannot provide any history, but her sisters state that she seems to have been drinking water excessively all day.

  • Paranoid schizophrenia

  • Major depressive disorder

  • Hypertension (no medications)

  • Type 2 diabetes mellitus (diet-controlled)

  • Lorazepam (Ativan) 0.5 mg, 1 each morning, 3 at night

  • Esomeprazole (Nexium) 40 mg daily

  • Ziprasidone (Geodon) 80 mg, 2 tablets daily

  • Sertraline (Zoloft) 100 mg daily

Patient recently moved from Indiana to Alabama. No alcohol or illegal drugs. Stopped smoking 6 months ago.

Vital signs: Temperature 98.9° F, pulse 78, respirations 20, blood pressure 155/79

General: No acute distress

Head, eyes, ears, nose, and throat: Normocephalic, atraumatic. Pupils 3 mm and reactive. Oral mucosa moist.

Neck: Supple

Chest: Clear to auscultation and percussion

Heart: S1, S2 within normal limits

Abdomen: Clear to auscultation, no tenderness, no organomegaly

Extremities: No edema

Complete blood count (CBC): hemoglobin 11; hematocrit 31; white blood cell count 11,600; platelets 354,000.

Electrolyte panel: Sodium 116 mEq/L; potassium 3.9 mEq/L; chloride 80 mEq/L; bicarbonate 15 mEq/L; blood urea nitrogen (BUN) 7; creatinine 0.4 mg/dL; glucose 177 mg/dL; calcium 9.0.

  • What treatment would you recommend?

  • What other diagnostic tests does the patient need?

  • Speculate on the etiology of the hyponatremia.

  • Why is the bicarbonate decreased? Speculate on the etiology of this abnormality.

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