Hyponatremia physical examination: Difference between revisions

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{{Hyponatremia}}
{{Hyponatremia}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{Saeedeh}}


==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].


OR
Hyponatremia by itself has the signs of CNS function impairment and the other signs which can be detected in the physical exam are caused by the etiologies of hyponatremia. Depending on the severity of hyponatremia, signs vary from subtle cognitive impairment to brain death. Patients who present with hyponatremia, depending on the underlying causes, may present with different signs in clinical evaluation.


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
==Physical Examination ==
 
* [[Nausea]] and [[malaise]] are the earliest signs of hyponatremia.
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
==Physical Examination==
{| class="wikitable"
{| class="wikitable"
!<big>Classification</big>
!<big>Classification</big>
Line 26: Line 16:
|'''Hypervolemic'''
|'''Hypervolemic'''
'''hyponatremia'''
'''hyponatremia'''
|Peripheral edema, ascites, pulmonary edema, raised JVP,clinical signs of underlying causes
|[[Peripheral edema]], [[ascites]], [[pulmonary edema]], raised [[JVP]],clinical signs of underlying causes
|-
|-
|'''Euvolemic hyponatremia'''
|'''Euvolemic hyponatremia'''
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|-
|-
|'''Hypovolemic hyponatremia'''
|'''Hypovolemic hyponatremia'''
|Dry mucous membrane, decreased skin turgor, hypotension (orthostatic), tachycardia
|Dry mucous membrane, decreased skin turgor, [[Orthostatic hypotension|hypotension (orthostatic)]], [[tachycardia]]
|}
|}
Determination of volume status i.e. dehydration, oedema, ascites should be carried out.[29] Patients with clinical signs of volume depletion (e.g. orthostatic decreases in blood pressure and increases in pulse rate, dry mucus membranes, decreased skin turgor) should be considered hypovolemic. When available, direct hemodynamic measurements can provide corroboration of the clinical impression.
to see the causes of hyponatremia, click [[Hyponatremia causes#Causes|here]].
* look for Signs of hypothyroidism
* Look for signs of Endocrine disease like [[adrenal insufficiency]], [[hypothyroidism]], hypopituitarism
* look for adrenal insufficiency
* Clinical signs of CHF, RF, 
* Detailed examination to detect any CNS or lung lesion.
* Detailed examination to detect any lesions in the body to rule out any malignacies
 
* Look for signs of infectious disease
* Physical examination of patients with [disease name] is usually normal.
* Look for signs of drus use
OR
* Look for any signs of CNS involvement
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 
===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with hyponatremia may appear with wide range of presentations from no discomfort to severe distress.


===Vital Signs===
===Vital Signs===
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*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Kussmal respirations may be present  
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse may be present
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]] may be present


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
* Skin examination of patients with hyponatremia varies depend on the underlying causes like hypothyroidism, CHF, adrenal insufficiency
OR
 
*[[Cyanosis]]  
*[[Cyanosis]]  
*[[Jaundice]]
*[[Jaundice]]
Line 67: Line 53:
* Bruises
* Bruises


<gallery widths="150px">
===HEENT===
 
* HEENT examination of patients with hyponatremia varies depending on the causes: tumor, thyroid diseases
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
* Abnormalities of the head/hair may include hair loss, brittle hair
* HEENT examination of patients with [disease name] is usually normal.
OR
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Evidence of trauma
* Icteric sclera  
* Icteric sclera  
* [[Nystagmus]]  
* [[Nystagmus]]  
* Extra-ocular movements may be abnormal
* Extra-ocular movements may be abnormal in case of tumor-associated hyponatremia
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
*Ophthalmoscopic exam may be abnormal with findings of brain edema
* Hearing acuity may be reduced
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Weber test]] may be abnormal
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
*[[Rinne test]] may be positive  
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
* Neck examination of patients with hyponatremia may lead to other causes like tumors
OR
 
*[[Jugular venous distension]]
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
Line 104: Line 79:


===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with severe hyponatremia
OR
 
* Asymmetric chest expansion / Decreased chest expansion
* Asymmetric chest expansion / Decreased chest expansion
*Lungs are hypo/hyperresonant
*Lungs can be hypporesonant/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Rhonchi
Line 113: Line 88:
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Egophony]] present may be present
*[[Bronchophony]] present/absent
*[[Bronchophony]] present may be present
*Normal/reduced [[tactile fremitus]]
*Reduced [[tactile fremitus]] may be present


===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with hyponatremia
OR
 
*Chest tenderness upon palpation
*Chest tenderness upon palpation may be present
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of  
*[[Heave]] / [[thrill]]
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Friction rub]]
Line 129: Line 104:
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] may be heard .


===Abdomen===
===Abdomen===
Abdominal examination of patients with [disease name] is usually normal.
OR
*[[Abdominal distention]]  
*[[Abdominal distention]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant  
Line 144: Line 116:


===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
*Point tenderness over vertebrae  
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Costovertebral angle tenderness bilaterally/unilaterally
Line 152: Line 122:


===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
*Patient can be oriented to persons, place, and time
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Altered mental status
* Glasgow coma scale is ___ / 15
* Glasgow coma scale has to be checked
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
* In case of brain edema or herniation involvement of cranial nerves may be seen
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Abnormal gait ataxic (cerebellar) gait/steppage gait/waddling gait / choreiform gait / Parkinsonian gait / sensory gait may be present
*Positive/negative Trendelenburg sign
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Normal finger-to-nose test / Dysmetria my be present
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
OR
*[[Clubbing]]  
*[[Clubbing]]  
*[[Cyanosis]]  
*[[Cyanosis]]  

Latest revision as of 20:38, 2 July 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Saeedeh Kowsarnia M.D.[2]

Overview

Hyponatremia by itself has the signs of CNS function impairment and the other signs which can be detected in the physical exam are caused by the etiologies of hyponatremia. Depending on the severity of hyponatremia, signs vary from subtle cognitive impairment to brain death. Patients who present with hyponatremia, depending on the underlying causes, may present with different signs in clinical evaluation.

Physical Examination

Classification Clinical signs
Hypervolemic

hyponatremia

Peripheral edema, ascites, pulmonary edema, raised JVP,clinical signs of underlying causes
Euvolemic hyponatremia Clinical signs of underlying causes
Hypovolemic hyponatremia Dry mucous membrane, decreased skin turgor, hypotension (orthostatic), tachycardia

to see the causes of hyponatremia, click here.

  • Look for signs of Endocrine disease like adrenal insufficiency, hypothyroidism, hypopituitarism
  • Clinical signs of CHF, RF,
  • Detailed examination to detect any lesions in the body to rule out any malignacies
  • Look for signs of infectious disease
  • Look for signs of drus use
  • Look for any signs of CNS involvement

Appearance of the Patient

  • Patients with hyponatremia may appear with wide range of presentations from no discomfort to severe distress.

Vital Signs

  • High-grade / low-grade fever
  • Hypothermia / hyperthermia may be present
  • Tachycardia with regular pulse or (ir)regularly irregular pulse
  • Bradycardia with regular pulse or (ir)regularly irregular pulse
  • Tachypnea / bradypnea
  • Kussmal respirations may be present
  • Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse may be present
  • High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure may be present

Skin

  • Skin examination of patients with hyponatremia varies depend on the underlying causes like hypothyroidism, CHF, adrenal insufficiency

HEENT

  • HEENT examination of patients with hyponatremia varies depending on the causes: tumor, thyroid diseases
  • Abnormalities of the head/hair may include hair loss, brittle hair
  • Evidence of trauma
  • Icteric sclera
  • Nystagmus
  • Extra-ocular movements may be abnormal in case of tumor-associated hyponatremia
  • Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
  • Ophthalmoscopic exam may be abnormal with findings of brain edema
  • Hearing acuity may be reduced
  • Weber test may be abnormal
  • Rinne test may be positive
  • Facial tenderness
  • Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae

Neck

  • Neck examination of patients with hyponatremia may lead to other causes like tumors

Lungs

  • Pulmonary examination of patients with severe hyponatremia
  • Asymmetric chest expansion / Decreased chest expansion
  • Lungs can be hypporesonant/hyperresonant
  • Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
  • Rhonchi
  • Vesicular breath sounds / Distant breath sounds
  • Expiratory/inspiratory wheezing with normal / delayed expiratory phase
  • Wheezing may be present
  • Egophony present may be present
  • Bronchophony present may be present
  • Reduced tactile fremitus may be present

Heart

  • Cardiovascular examination of patients with hyponatremia

Abdomen

Back

  • Point tenderness over vertebrae
  • Sacral edema
  • Costovertebral angle tenderness bilaterally/unilaterally
  • Buffalo hump

Genitourinary

  • A pelvic/adnexal mass may be palpated
  • Inflamed mucosa

Neuromuscular

  • Patient can be oriented to persons, place, and time
  • Altered mental status
  • Glasgow coma scale has to be checked
  • Hyperreflexia / hyporeflexia / areflexia
  • Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
  • Muscle rigidity
  • Proximal/distal muscle weakness unilaterally/bilaterally
  • In case of brain edema or herniation involvement of cranial nerves may be seen
  • Unilateral/bilateral upper/lower extremity weakness
  • Unilateral/bilateral sensory loss in the upper/lower extremity
  • Positive straight leg raise test
  • Abnormal gait ataxic (cerebellar) gait/steppage gait/waddling gait / choreiform gait / Parkinsonian gait / sensory gait may be present
  • Positive/negative Trendelenburg sign
  • Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
  • Normal finger-to-nose test / Dysmetria my be present

Extremities

  • Clubbing
  • Cyanosis
  • Pitting/non-pitting edema of the upper/lower extremities
  • Muscle atrophy
  • Fasciculations in the upper/lower extremity

References

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