Asked to see a young man who had been admitted 5 days earlier with what appeared to be extreme alcohol induced hepatitis. In addition to an extreme liver panel, but not so bad ultrasound, his proteins were very low for a young previously healthy man and his sodium was only 123. The residents had the presence of mind to address the hyponatremia in the usual way. Osmolality 335 in serum, 691 in urine, sodium 150 in urine. This is pseudohyponatremia of extreme degree, though not recognized for that. After some testing, his cortisol was low at 3.1 so they called me. The original lab looked like there was some other substance restricting plasma volume so I had the residents repeat the serum osmolality which had come down to 290, still inappropriate to the sodium of 129. Since his glucose, bun and proteins were not high, this is usually from a lipid problem. Sure enough, the cholesterol was 1208 and ldlc 1098, by far the highest numbers I have ever seen. I assume the liver dysfunction impairs some of the serum cholesterol disposal enzymes.
Not sure why it took 5 days to figure this out.
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