CASE:
A 52-year-old male hypertensive patient resident of urban Karachi was brought to the emergency department after an episode of generalized tonic-clonic seizure accompanied by blurring of vision and fall. He was admitted to the medicine ward and was diagnosed with electrolyte imbalance and urinary tract infection (UTI), and was treated accordingly. His GCS (Glasgow Coma Scale) was 15/15 and he was vitally stable. However, later his lab workup indicated marked hyponatremia of unknown cause. The patient’s detailed history and examination was done which revealed that he had been suffering from persistent depressive disorder for the past 10 years, since then he had been taking antipsychotics and antidepressants. Consequently, he was referred to psychiatry for further evaluation and assessment.
This anxious looking patient was brought to the psychiatric outpatient department where his thorough history and complete mental state examination deduced persistent depressive disorder for the past 10 years. Subjectively and objectively he had a low mood. Furthermore, some of his depressed episodes were defined as ‘weeping spells’ in addition to difficulty in sleeping by the attendant.
During the conversation the patient’s speech seemed normal and relevant in tone, rate and volume. His thought process was comprehensive and the content of his thoughts did not contain any suicidal or homicidal tendencies apart from some concerns regarding his future. There was no history of thought interferences, delusions, hallucinations and/or obsessions present.
His cognition was intact in time, place and person and he was fully aware of his ongoing condition. The patient reported no history of any sort of substance abuse, smoking and alcohol consumption.
Patient was hospitalized a few years back due to similar psychiatric complaints and was then discharged after being advised to continue the same treatment. He had been taking a combination therapy of antipsychotics and antidepressants. When admitted to the medicine ward his current medications included paroxetine 20 mg, quetiapine 25 mg and olanzapine 5 mg; all taken orally at bedtime. The previous medication regime was altered when it was confirmed that his unknown hyponatremia was due to the long-term use of SSRI. Therefore, paroxetine was immediately discontinued and was then replaced with atypical antidepressant along with benzodiazepine. Hence, he was prescribed Tab. Mirtazapine 15mg PO x HS and Tab. Clonazepam 0.5mg ½ - HS.
The first table (figure 1) outlines vitals of the patient which depicts that he remained vitally stable. The findings of his labs are summarized in the second table below (figure 2) which show that the patient had significant hyponatremia upon admission and his sodium levels increased from 111 mEq/L to 130 mEq/L during the course of his 4 days treatment in the medicine ward.