I am tired

 Mr R is a 70-year-old retired engineer. Mild diabetic and hypertensive on medication. He underwent a successful coronary artery bypass surgery eight years back and since then he has been seeing me twice a year with out fail. Lately however, he has not been able to keep up this schedule for many reasons. One of them being the strong rumor that I have given up practice and have gone away to the US to be with my daughter. Substantiating to this, Mr. R on several occasions had found my consulting chambers locked and my neighbors informing him that doctor has stopped practice. While the first one has no basis the second one has some. Two years ago, I took a deliberate decision to be available to only those who book prior appointment and to keep the doors open only at that time and keep them closed rest of the time. This information given to my well-meaning neighbors resulted in their informing those who came with out appointment and finding the doors shut to  believe that I have shut practice!

Be that as it may, let me get  to  back to Mr. R. He joyfully,[according to him] found out that I am alive and kicking and have not stopped seeing patients. And thus, here he is now, in front of me.

After the usual pleasantries, I  asked him,’ what is the problem’

I am extremely tired, can’t walk even half a km’ he said

Since when, I asked. In the past two weeks he replied.

What have been doing in the last two weeks, I asked

‘ Fearing worst, I went to see my cardiologist and got tests done, he showed me the cardiology test reports and the prescription. All the reports were normal, and he was told not to worry and take the vitamin pills  and get back when due.

I proceeded to examine him. Like his cardiologist ,I too found him with normal pulse, BP with no evidence of failing heart.

Now I am faced with the problem of why is Mr. R is having this recent onset tiredness?

A thought occurred, could he be having low sodium levels? He gave no history of vomiting, diarrhea, recent infection which could have caused his  low sodium and weakness.

How  much water, are you drinking? I asked. ‘ At least two liters in the morning and may be another two during the day, he replied. No doctor, more than that, it is now summer, he is always drinking, his wife chimed in her input.

Is he on low salt diet, ? was my next question

Yes doctor, since my surgery, I am on low salt diet, he replied

Here is a possible explanation for Mr. R’s tiredness. Onset of summer, high fluid intake, low salt intake resultant hyponatremia [low sodium] causing tiredness.

I asked the patient to get his blood electrolytes checked urgently and drink a glass of lime juice, with half spoonful of salt  three times a day and restrict his water intake awaiting the results

But then doctor, his BP will go up if he takes so much of salt, this was the wife’s worry

‘Unlikely in the short run’, I reassured her

With that, they took my leave.

That was three days ago, and there was no news from Mr R or his wife. Now I was worried. Did I miss any, is the patient alright or in serious trouble? Is he in the hospital?

I called him, His wife took the call, I asked her ,’how is your husband doing?

‘Daaktre,[doctor in kannada]’ He is perfectly normal and has now gone for his walk, I wanted to ask u, How long does he need to take this extra salt? She replied

What about the test results? I asked

We did not go, as he was feeling normal, she said and wanted to know if he still needs to do the test?

Two weeks of illness, got cured by two spoonful of salt!