B.A.M., an 88-year-old man is admitted to the Internal Medicine Department after being admitted to the emergency department from the day-care center to the outpatient clinic due to an episode of disconnection.
The patient has been a widower for seven years, lives at home with a caregiver and has good social and family support.
Following usual treatment with: atenolol (25 mg/day), acetylsalicylic acid (300 mg/day prior to acetylsalicylic acid (40 mg/day), nitroglycerin (parche, 5 mg/1⁄2 chloroquine), enalapril (50 mg/2.5 mg).
His personal history included: hypertension under treatment.
Ischemic heart disease (AMI in 1995).
Peripheral arterial disease followed by vascular surgery.
Prostatism with high-stable PSA.
Hypothyroidism under treatment.
Long-standing depressive syndrome, for 10 years in treatment with benzodiazepines and different antidepressants, always by their primary care physician (PCP).
No other psychiatric history.
The patient had two previous admissions:
The patient was admitted to the Internal Medicine Department three years ago for hyponatremia plasmatic 116 mEq/l, which progressed with functional impairment.
The family reported a sudden worsening of the patient from two days before admission, with urinary incontinence, partial disorientation in time and space, and also associated a presumed worsening of the depressive symptoms of the patient with restlessness (75mg).
Fluid restriction was performed and treatment with diuretic hydrochlorothiazide (50 mg/day) and sertraline (75 mg/day) was discontinued recently.
She was discharged with a blood Na of 127 mEq/l.
The main diagnosis at discharge was "Hyponatremia probably due to diuretics".
Another second admission 20 months ago in the Neurology Service after visiting the hospital emergency department complaining of dizziness with the gyrus of objects at home, without nausea or vomiting, with a feeling of discomfort in the lower limbs and feeling of discomfort.
The patient was not under treatment with any diuretic, and 15 days before admission antidepressant medication was reintroduced in his usual treatment (citalopram 30 mg/day) due to worsening of his depressive symptoms.
He was admitted with a plasma Na of 114 mEq/l.
They were performed among other cranial tests in which there were no intra- or extra-axial hemorrhagic lesions or space-occupying lesions, and moderate supratentorial CT scan of the head and white matter lesions.
Water restriction and citalopram removal were performed.
The patient was discharged after 10 days with a Na of 125 mEq/l and a diagnosis of SIADH-induced hypernatremia secondary to citalopram.
Four weeks before the current admission, her new PCP prescribed sertraline 25 mg/day for low mood, anxiety and apathy.
The patient had been bedridden since his last admission without antidepressant treatment.
According to the family, during these weeks they are progressively noticed with greater clumsiness at the motor level, brachypsychic and psychomotor inhibition.
The day before going to the emergency room, the dose increased to 50 mg/day due to lack of improvement.
The patient is brought to the emergency room for an episode of intense sleepiness of about ten minutes duration that only responds to painful stimuli, when recovering later presents incoherent language.
In the emergency assessment, the patient is in a basal situation, without motor focus and oriented in time and space.
Physical examination showed no significant findings, and neurological examination showed only motor slowness and tendency to sleepiness.
Complementary tests showed hyponatremia of 116 mEq/l, increased urinary osmolarity (531 mOsm/kg) and decreased plasma osmolarity (254 mOsm/Kg).
Chest radiography and ECG showed no relevant findings.
The patient was admitted to Internal Medicine with a diagnosis of severe symptomatic hypotonic hyponatremia secondary to thiazide therapy associated with SSRI.
Treatment with sertraline was suspended, fluid restriction with balance was indicated and isotonic saline was prescribed until normalization of plasma sodium levels.
After several days of admission, part of the consultation to the Psychiatry Department was attended for clinical evaluation and decision regarding antidepressant pharmacological treatment.
The patient has depressive symptoms with high levels of anxiety and intense hypochondriac fears.
Both the patient and the family require another antidepressant treatment, since in recent years in the periods in which he had been without treatment there had been a clear clinical worsening.
It was decided to start treatment with mitopine 15 mg/day with an increase to 30 mg/day after the first week of treatment and weekly controls of sodium plasma levels during the first 3-4 weeks and later on more tapered patients.
At discharge, antihypertensive treatment with enalapril is also recommended, avoiding associations with thiazide diuretics.
