Hyponatremia without obvious primary cause

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    90 years old very confused female patient came with 118 Na and Hypertension(200/100).

    Urinalysis, random urine Na, random urine osmolality, random urine creatinine are all WNL Am cortisol and TSH were WNL. Pt is diabetic and currently is on sliding scale.(Metformin was held) CT of head were negative.

    Abnormal EKG was noted and troponin was negative. Cardiologist saw the patient as well. the night when she was admitted. Metoprolol and digoxin were discontinued due to 1st degree AV heart block or possible 2nd degree heart block. HCTZ was discontinued. Hypertension has been treated with prn clonidine, scheduled Norvasc and losartan.

    There is no sign of dehydration. Pt seemed to be euvolemic. Patient doesn't have hx of CHF. No edema noted. Serum Bun/ Cr were normal. Pt started Fluid restriction 1000ml/day. NaCl orally 2g bid, prostat 1 pack bid were added.

    Sodium stayed pretty low whole time it went down as low as 115. Nephrolosist ordered 3 % saline 60cc (30cc/hr) at this point and decreased fluid restriction to 750ml/day. The 3% saline worked and Na went to 121 1 hour after 3 % saline was infused. The next morning, Random urine sodium dropped from 61 to 13. Can anyone explain this part(Random sodium was in Normal range and dropped low the next day)? Thanks.

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