Hyponatremia

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for ‍newknown hyponatremia



Lab results:

Na ‍, K ‍ ‍normal, Cl ‍ ‍normal

BUN ‍ ‍normal, creatinine ‍ ‍normal, Albumin ‍ ‍normal

Ca ‍ ‍normal, Mg ‍ ‍normal, Phosphate ‍ ‍normal

Urinalysis ‍ ‍normal

Osmolality ‍



Associated symptoms: *Try using right-click for negatives*

‍none

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍diarrhea, ‍ episodes ‍per day, ‍

‍dehydration

‍shortness of breath

‍orthopnea

‍leg swelling, ‍rightleftsymmetrical

‍muscle weakness

‍muscle cramps

‍fatigue

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍confusion

‍seizures



Contributing factors:

‍low-sodium diet

‍excessive fluid intake

‍excessive alcohol intake

no history of: ‍dehydration, ‍excessive sweating, ‍chronic kidney disease, ‍heart failure, ‍cirrhosis, ‍SIADH, ‍hypothyroidism, ‍adrenal insufficiency

no use of: ‍diuretics, ‍antidepressants, ‍antipsychotics, ‍carbamazepine, ‍chemotherapy, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Hyponatremia ‍likelysuspectedpossible

DDx: hypovolemic hyponatremia, euvolemic hyponatremia, hypervolemic hyponatremia, SIADH, adrenal insufficiency, diuretic use, psychogenic polydipsia, renal failure, heart failure, liver cirrhosis, nephrotic syndrome, hypothyroidism, lung disease, lung cancer, cerebral salt wasting syndrome, medication side effect (e.g., SSRIs, antiepileptics), excessive water intake, beer potomania, tea and toast syndrome, malnutrition, exercise-associated hyponatremia, ecstasy use, postoperative hyponatremia





PLAN:

Investigations:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍osmolality, ‍lipid profil, ‍albumin, ‍proteins

- Urine: ‍urinalysis, ‍osmolality, ‍sodium

- ECG

- Chest X-ray

Treatments:

If hypervoemic:

- Fluid restriction to ‍1.5L1L0.5L per day

- ‍Diuretics

- ‍Tolvaptan

If euvolemic:

- Fluid restriction to ‍1.5L1L0.5L per day

- Stop offending medications ‍HCTZindapamide

- NaCl 1g po BID

- Hypertonic saline 3% ‍50100200 ml IV ‍over 1 hourover 4 hours use with caution

If hypovolemic:

- Normal saline 0.9% ‍5001000 ml IV ‍bolusover 1 hourover 4 hours if hypovolemic

- Natremia correction max 10 per 24h

- Increase dietary sodium

Further care:

- Repeat Na in ‍ ‍hoursdaysweeks

- Referral to internist

- Referral to nephrologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as headache, nausea, or vomiting

- Referral to ER if severe headache, confusion, seizures, or loss of consciousness occurs