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.