A patient presents to the ED for evaluation of nausea, vomiting, headache and confusion. The patients wife informs you that he ran a marathon earlier in the day and has not felt good since. What electrolyte imbalance are you most concerned about?

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A patient in the ED with nausea, vomiting, headache, and confusion after a marathon raises concern for an electrolyte disturbance related to hydration status and solute balance. 
Option 1: sodium. Hyponatremia is a classic concern in endurance athletes who consume excessive free water or have increased antidiuretic hormone release, leading to dilutional low sodium. Neurologic symptoms like confusion and headache fit hyponatremia, and GI symptoms such as nausea and vomiting can accompany it. This makes sodium imbalance the most plausible culprit here.
Option 2: calcium. While calcium abnormalities can cause neuromuscular and CNS symptoms, they’re less commonly triggered acutely by endurance exercise or hydration status alone. Hypercalcemia or hypocalcemia would present with more specific signs (e.g., polyuria, bones, stones, psychiatric overtones in hypercalcemia; tingling or Chvostek/Trousseau signs in hypocalcemia) rather than the acute triad described.
Option 3: magnesium. Magnesium disturbances can cause confusion and neuromuscular symptoms, but the presentation after prolonged exertion is not the typical context for magnesium imbalance. Severe hypomagnesemia could occur with poor intake or diuretics, yet it would be less immediately tied to marathon-related exertion without other signs such as arrhythmias or characteristic reflex changes.
Option 4: phosphate. Phosphate abnormalities can occur in malnutrition or refeeding syndromes or with shifts in acid-base status, but the specific scenario of post-marathon nausea, vomiting, headache, and confusion aligns more directly with water balance and hyponatremia rather than isolated phosphate derangements. Phosphate disturbances alone would not typically be the leading concern in this setting.
Overall, the scenario most strongly points to a sodium imbalance (hyponatremia) as the primary concern due to the neurologic symptoms after endurance activity and hydration context, while the other electrolytes are less consistent with the described presentation.

A patient presents to the ED for evaluation of nausea, vomiting, headache and confusion. The patients wife informs you that he ran a marathon earlier in the day and has not felt good since. What electrolyte imbalance are you most concerned about?

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