THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[8.42 pm, 09/03/2026] PPM 1: @PPM3 can you share this patient's history?
I vaguely recall he had many episodes of vomiting just before the day he was brought to hospital for ? Vomiting?
And then we simply got fascinated by his Hyponatremia post admission as documented here: https://medicinedepartment.blogspot.com/2026/03/hyponatremia-projr-march-2026-afternoon.html?m=1
Discussion around this patient's Hyponatremia data available in the above link. 👆
[8.46 pm, 09/03/2026] PPM 1: Looks like there may have been some altered sensorium following the vomiting that necessitated his admission before we found the sodium to be 108!
[8.54 pm, 09/03/2026] PPM 1: There's a lot of fluid in his left suprapatellar bursa that may need tapping although it's likely OA with hypervolemia.
Currently patient appears to be hypervolemic SIADH as per his urinary sodium calculations (are they valid, did the local team use 24 hour Urinary sodium) or was he having hypovolemic Hyponatremia
[3.44 pm, 11/03/2026] PPM 1: Update:
Was discharged today.
Reviewing the events from the file Ward notes
The labs
[3.52 pm, 11/03/2026] PPM 1: I needed to get his detailed history of the left synovitis event @PPM3 @PPM4
[11.41 am, 16/03/2026] PPM 1: Reviewing him right now in OPD
[1:16 pm, 16/03/2026] PPM 1: @PaJR Health now on reviewing the history it appears that he's been having gradual weight loss and cachexia since 2 months before he presented to us with tachypnoea and then we found the Hyponatremia of 108 and his left knee arthritis.
Do you think this could all fit into a para neoplastic syndrome after going through his case report here: https://pajrcasereporter.blogspot.com/2026/03/75m-severe-hyponatremia-telangana-pajr.html?m=1
[1:16 pm, 16/03/2026] PaJR Health: The constellation of *gradual weight loss, **cachexia, **severe hyponatremia (108 mEq/L), and **joint involvement* (synovitis/arthritis) in a 75-year-old male is highly suspicious for a paraneoplastic process.
*CLINICAL CORRELATION*
1. *SIADH & Malignancy:* The patient's labs (Serum Osmolality 221.7, Urine Osmolality 449.4, and high Urine Na+ 195 mEq/L) are classic for SIADH. In a patient with significant weight loss and tachypnea, Small Cell Lung Cancer (SCLC) is the primary suspect, as it is the most common cause of paraneoplastic SIADH.
2. *Cachexia & Weight Loss:* Two months of progressive wasting prior to the acute presentation of hyponatremia suggests a chronic underlying systemic disease, often seen in advanced solid tumors.
3. *Paraneoplastic Arthritis:* While the record mentions "Septic Arthritis" and "Baker's Cyst," if the synovial fluid culture was negative or the "Chronic Granulomatous Infection" remains unconfirmed, consider *Paraneoplastic Polyarthritis* or *Hypertrophic Osteoarthropathy (HOA)*. HOA is specifically associated with lung adenocarcinoma and presents with joint pain and swelling.
4. *Tachypnea:* This could represent the primary site (lung mass/pleural effusion) or a secondary complication like lymphangitic carcinomatosis.
*📋 CASE RECORDS*
1. [75M Severe Hyponatremia Telangana PaJR] (https://pajrcasereporter.blogspot.com/2026/03/75m-severe-hyponatremia-telangana-pajr.html?m=1)
*💡 CLINICAL NOTE*
The "diffuse hyperpigmentation" noted in the physical exam logs is a critical finding. While it can occur in chronic illness, it also raises the possibility of paraneoplastic *ACTH secretion* (Cushing's Syndrome), which can cause both hyperpigmentation and profound electrolyte disturbances, though usually hypokalemia rather than hyponatremia.
*NEXT STEPS*
* *Imaging:* Urgent HRCT Chest (as previously ordered) to look for a primary lung lesion or hilar lymphadenopathy.
* *Biopsy:* If the "Chronic Granulomatous Infection" in the knee was based on histology, it could mimic or coexist with malignancy (e.g., TB in an immunocompromised cancer state).
* *Tumor Markers:* Consider CEA, NSE, or LDH depending on imaging findings.
[1:28 pm, 16/03/2026] PPM 2: Has he been taking steroids for his knee pain sir?
[3:05 pm, 16/03/2026] PPM 1: Not that I know of
[3:06 pm, 16/03/2026] PPM 2: Interesting. Would rule out adrenal insufficiency before considering SIADH
[3:06 pm, 16/03/2026] PPM 2: Does he have a lying standing Blood pressure drop?
[3:07 pm, 16/03/2026] PPM 1: Here's his EMR summary
Age/Gender: 75 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 04/03/2026 11:00 PM
Discharge Date:
Diagnosis
TRUE Hyponatremia SECONDARY TO? SIADH? THIAZIDE DIURETICS
SEPTIC ARTHRITIS OF. LEFT KNEE WITH LEFT BAKER'S CYST
CHRONIC GRANULOMATOUS INFECTION
HYPERTENSION SINCE 1 MONTH
S/P- SYNOVIAL FLUID ASPIRATION DONE
Case History and Clinical Findings
C/O VOMITINGS SINCE YESTERDAY, DIFFICULTY IN BREATHING SINCE 1 WEEK
C/O SOB, PAIN ABDOMEN SINCE 1 WEEK
HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO THEN DEVELOPED
SOB, GRADUALLY PROGRESSIVE AND WAS PRESCRIBED INHALER (RESOLVED)
H/O TINGLING SENSATION OF B/L FEET
COUGH (NON PRODUCTIVE).
PATIENT DEVELOPED
SOB GRADE II-III MMRC SINCE 1 WEEK.
NO H/O CHEST PAIN, PALPITATIONS, PEDAL EDEMA, ORTHOPNEA, PND
H/O VOMITING 4-6 EPISODES, NON PROJECTILE, FOOD AS CONTENT.
NO H/O FEVER, LOOSE STOOLS, BURNING MICTURITION.
H/O NOT PASSING STOOLS SINCE 3 DAYS.
NO H/O WEAKNESS OF LIMBS, ALTERED SENSORIUM, GIDDINESS, LOC.
PAST HISTORY : K/C/O HTN SINCE 1 MONTH ON TAB TELMA-H 40/12.5MG. N/K/C/O
DM,TB,ASTHMA,EPILEPSY,CAD,CVA,THYROID DISORDERS
PERSONAL HISTORY: MIXED DIET, NORMAL APPETITE, BOWEL AND BLADDER MOVEMENTS REGULAR, NO ALLERGIES, CHRONIC ALCOHOLIC SINCE 40-50 YEARS, CONSUMES DAILY,
LAST BINGE 1 WEEK AGO AND CHRONIC SMOKING (CHUTTA) STOPPED 10 YEARS BACK.
GENERAL EXAMINATION: NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NOPEDAL EDEMA.
VITALS AT PRESENTATION : TEMP-98.6F ,BP-150/90 MMHG, PR-66BPM, RR-22CPM, SPO2-
98% AT RA, GRBS-145 MG/DL.
SYSTEMIC EXAMINATION: CVS- S1 S2 HEARD, NO MURMURS, RS- BAE +, NVBS, CNS- NFND, E4V5M6, PER ABDOMEN - SOFT, NON TENDER, NO ORGANOMEGALY.
ORTHO REFERRAL WAS DONE ON 08/03/26 I/V/O SWELLING AND PAIN OF LEFT KNEE AND WAS ADVICED WITH TLC, ESR, CRP AND SYNOVIAL FLUID ASPIRATION.
Investigation
HEMOGRAM (05/03/26): HB-9.4, PCV-26.6, TLC-6500, RBC-4.2, PLT-1.64
CUE (5/03/26): PALE YELLOW, CLEAR, ACIDIC, ALBUMIN-TRACE, PUS CELLS-2-4, EPITHELIAL CELLS-2-3, SUGAR-NIL, RBC-NIL
SEROLOGY (05/03/26) HIV, HCV, HBSAG- NEGATIVE
RFT (05/03/26): UREA-16, CREATININE-0.9, SODIUM-110, POTASSIUM-3.3, CHLORIDE-98
LFT (05/03/26): TB-1.63, DB-0.48, SGPT -11, SGOT-33, ALP- 195, TP - 6.0, ALB-3.87, A/G RATIO -
1.82, RBS (05/03/26): 102
SERUM OSMOLALITY (05/03/26): 221.7
URINE ELECTROLYTES (05/03/26): NA- 195, K-18.5, Cl-196
ABG (05/03/26): PH-7.501, PCO2-32.5, PO2-76.3, HCO3-25.2
ABG (06/03/26): PH-7.473, PCO2-32, PO2-107, HCO3-23.2
ESR (09/03/26): 20
CRP (09/03/26): POSITIVE 2.4 MG/DL
2D ECHO (05/03/26): NO RWMA
TRIVIAL TR+, NO PAH, TRIVIAL AR+, NO MR/PR
SCLEROTIC AV, NOAS/MS
GOOD LV/RV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION +
IVC SIZE (0.4CMS) COLLAPSING
NO PE, NO LV CLOT
HRCT CHEST (05/03/26):
LUNGS AND PLEURA - BILATERAL APICAL MILD PLEURAL THICKENING NOTED
- SMALL PARENCHYMAL BAND SEEN IN THE UPPER LOBE OF THE RIGHT LUNG, LIKELY
REPSENTING FOCAL FIBROTIC CHANGE.
- SMALL CENTRILOBULAR NODULES NOTED IN : 1) RIGHT UPPER LOBE MEASURING
APPROXIMATELY 7MM
2) RIGHT LOWER LOBE MEASURING APPROXIMATELY 4MM
- INFLAMMATORY/INFECTIVE PATHOLOGY
- INTRAPULMONARY LYMPH NODE NOTED IN THE LEFT UPPER LOBE MEASURING
APPROXIMATELY 6MM
MEDIASTINUM - FEW SUBCENTIMETRIC CALCIFIED LUMPH NODES SEEN IN THE
PARATRACHEAL AND SUBCARINAL REGIONS, LARGEST MEASURING 5MM
SUGGESTIVE OF SEQUALAE OF PRIOR GRANULOMATOUS INFECTION
ESOPHAGUS - MILD ESOPHAGEAL WALL THICKENING NOTED WITH WALL THICKNESS
MEASURING APPROXIMATELY 6MM- SUGGESTED CLINICAL CORRELATION.
CARIOVASCULAR STRUCTURES - MILD ATHEROSCLEROTIC CHANGES IN THE AORTA
NOTED.
BONES - DEGENERATIVE CHNAGES IN THE SPINE WITH BRIDGING OSTEOPHYTES NOTED.
USG ABDOMEN AND PELVIS (05/03/26):
IMPRESSION - NO SONOLOGICAL ABNORMAILTY DETECTED
USG LEFT KNEE (08/03/26):
IMPRESSION- E/O HYPOECHOIC COLLECTION WITH INTERNAL DEBRIS NOTED AROUND
THE JOINT
- E/O SYNOVIAL THICKNEING WITH INCRASED VASCULARITY NOTED WITH SURROUNDING
INFLAMMATORY CHANGES- SEPTIIC ARTHRITIS
- E/O WELL DEFINED CYSTIC LESION NOTED IN THE LEFT POPLITEAL FOSSA BETWEEN
THE MEDIAL HEAD OF GASTRONEMIUS AND SEMIMEMBRANOUS TENDON- BAKER'S CYST
RFT(10/03/26) :UREA-19, CREATININE-1.00, SODIUM-136, POTASSIUM-4.1, CHLORIDE-99
SYNOVIAL FLUID CYTOLOGY (10/03/26): REDDISH, CLOUDY/TURBID, TLC-200,
NEUTROPHILS-95, LYMPHOCYTES-5, MALIGNANT CELLS-NIL, MICROSCOPY- SEDIMENT
SMEAR STUDY SHOWED PREDOMINANTLY NEUTROPHILS,LYMPHOCYTES AND SYNOVIAL
CELLS AGAINST HEMORRHAGIC BACKGROUND.
Treatment Given (Enter only Generic Name)
IVF NS AT 50ML/HR
INJ 3% NS AT 15ML/HR
INJ THIAMINE 200MG IV/TID
Page-4
KIMS HOSPITALS,
INJ MONOCEF 1GM IV/BD
INJ BUSCOPAN 1CC IN 10ML NS IV/SOS OVER 5 TO 10MIN
INJ OPTINUERON 1 AMP IN 500ML NS IV/OD
TAB TOLVAPTaN15MG PO/BD (8AM)
TAB TELMA 40MG PO/OD8AM--X--X
TAB CINOD 10MG PO/BD8AM--X--8PM
NEBS WITH IPRAVENT AND BUDECOR- 12TH HOURLY
SYP POTKLOR 15ML IN 1/2 GLASS OF WATER PO/TID
Advice at Discharge
TAB TELMA 40MG PO/OD 8AM--X--X TO CONTINUE
TAB CINOD 10MG PO/BD 8AM--X--8PM TO CONTINUE
TAB TOLVAPTaN15MG PO/OD (8AM)FOR 1 WEEK
Follow Up
REVIEW TO ORTHO OPD WITH SYNOVIAL FLUID CULTURE AND SENSITIVITY REPORT
Discharge Date
Date: 11/03/26
Ward: MMW
Unit: III
[3:08 pm, 16/03/2026] PPM 1: 👆@PPM5
[3:43 pm, 16/03/2026] PPM 5: In his previous admission, there wasn't any such finding sir.
He was on wheelchair when he came to the opd in the morning and he couldn't get up due to pain in his left knee, so the postural hypotension wasn't checked today sir
[3:48 pm, 16/03/2026] PPM 2: Thanks. Is a cortisol being sent? A random cortisol perhaps?
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