An elderly patient admitted with acute ischemic stroke. While in the hospital, his conscious level worsened. Neuro imaging did not suggest any cause for worsening. His laboratory parameters were as follows- serum sodium 118, blood urea= 31, plasma glucose=117. His urine output was 3200 ml. Patient’s family is keen know to cause of his ill health. How will you investigate further

An elderly patient admitted with acute ischemic stroke. While in the hospital, his conscious level worsened. Neuro imaging did not suggest any cause for worsening. His laboratory parameters were as follows- serum sodium 118, blood urea= 31, plasma glucose=117. His urine output was 3200 ml. Patient’s family is keen know to cause of his ill health. How will you investigate further

In this case, the elderly patient admitted with acute ischemic stroke is experiencing a worsening of consciousness despite neuroimaging not indicating any new neurological abnormalities.

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Given the abnormal laboratory parameters, including hyponatremia (serum sodium 118), elevated blood urea (31), and mildly elevated plasma glucose (117), further investigation is warranted to determine the cause of his deteriorating health status. Here’s how I would proceed with further investigation:

1. **Review of Medical History**: Conduct a thorough review of the patient’s medical history, including any pre-existing conditions, medications, recent changes in health status, or previous episodes of electrolyte imbalances.

• **Detailed Physical Examination**: Perform a comprehensive physical examination to assess the patient’s neurological status, hydration level, signs of fluid overload or dehydration, vital signs, and any other relevant clinical findings.

• **Assessment of Fluid Balance**: Evaluate the patient’s fluid balance, including intake and output, to determine if there are any underlying fluid disturbances contributing to his clinical presentation. Calculate the patient’s fluid balance and assess for signs of hyponatremia-related complications, such as cerebral edema or altered mental status.

• **Investigation of Hyponatremia**: Investigate the underlying cause of hyponatremia, considering differential diagnoses such as syndrome of inappropriate antidiuretic hormone secretion (SIADH), cerebral salt wasting syndrome (CSWS), adrenal insufficiency, congestive heart failure, or renal dysfunction. Further laboratory tests, including serum osmolality, urine osmolality, urine sodium, and thyroid function tests, may be necessary to establish the etiology of hyponatremia.

• **Assessment of Renal Function**: Evaluate renal function to determine if there are any underlying kidney-related issues contributing to the patient’s clinical presentation. This may involve assessing serum creatinine, blood urea nitrogen (BUN), urine output, and urine electrolytes to evaluate renal perfusion and function.

• **Monitoring of Glucose Levels**: Continuously monitor the patient’s blood glucose levels to ensure glycemic control and assess for any fluctuations or complications related to glucose metabolism, such as hyperglycemia-induced osmotic diuresis.

• **Neurological Assessment**: Reassess the patient’s neurological status, including level of consciousness, pupil size and reactivity, motor and sensory function, and signs of focal neurological deficits, to detect any new or evolving neurological abnormalities.

• **Consultation with Specialist Teams**: Consider consulting with specialist teams, such as nephrology, endocrinology, or neurology, to assist in the evaluation and management of the patient’s complex clinical presentation, particularly if there are concerns regarding specific organ systems or underlying medical conditions.

• **Communication with Family**: Maintain open and transparent communication with the patient’s family, providing them with regular updates on the patient’s condition, test results, and treatment plan. Address any concerns or questions they may have and involve them in the decision-making process regarding further investigations and treatment options.

By conducting a comprehensive investigation and collaborating with multidisciplinary teams, the underlying cause of the elderly patient’s deteriorating health status can be identified, allowing for targeted interventions and appropriate management to optimize patient outcomes.