Hypernatremia physical examination: Difference between revisions
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===Neuromuscular=== | ===Neuromuscular=== | ||
The neuromuscular physical exam findigs appear as a result of neuronal cell shrinkage and is positive for the following findings:<ref name="pmid21315305">{{cite journal| author=Furukawa S, Takaya A, Nakagawa T, Sakaguchi I, Nishi K| title=Fatal hypernatremia due to drinking a large quantity of shoyu (Japanese soy sauce). | journal=J Forensic Leg Med | year= 2011 | volume= 18 | issue= 2 | pages= 91-2 | pmid=21315305 | doi=10.1016/j.jflm.2010.11.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21315305 }} </ref><ref name="pmid2603957">{{cite journal| author=Heilig CW, Stromski ME, Blumenfeld JD, Lee JP, Gullans SR| title=Characterization of the major brain osmolytes that accumulate in salt-loaded rats. | journal=Am J Physiol | year= 1989 | volume= 257 | issue= 6 Pt 2 | pages= F1108-16 | pmid=2603957 | doi=10.1152/ajprenal.1989.257.6.F1108 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2603957 }} </ref><ref name="pmid2332498">{{cite journal| author=Lien YH, Shapiro JI, Chan L| title=Effects of hypernatremia on organic brain osmoles. | journal=J Clin Invest | year= 1990 | volume= 85 | issue= 5 | pages= 1427-35 | pmid=2332498 | doi=10.1172/JCI114587 | pmc=296588 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332498 }} </ref> | The neuromuscular physical exam findigs appear as a result of neuronal cell shrinkage and is positive for the following findings:<ref name="pmid21315305">{{cite journal| author=Furukawa S, Takaya A, Nakagawa T, Sakaguchi I, Nishi K| title=Fatal hypernatremia due to drinking a large quantity of shoyu (Japanese soy sauce). | journal=J Forensic Leg Med | year= 2011 | volume= 18 | issue= 2 | pages= 91-2 | pmid=21315305 | doi=10.1016/j.jflm.2010.11.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21315305 }} </ref><ref name="pmid2603957">{{cite journal| author=Heilig CW, Stromski ME, Blumenfeld JD, Lee JP, Gullans SR| title=Characterization of the major brain osmolytes that accumulate in salt-loaded rats. | journal=Am J Physiol | year= 1989 | volume= 257 | issue= 6 Pt 2 | pages= F1108-16 | pmid=2603957 | doi=10.1152/ajprenal.1989.257.6.F1108 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2603957 }} </ref><ref name="pmid2332498">{{cite journal| author=Lien YH, Shapiro JI, Chan L| title=Effects of hypernatremia on organic brain osmoles. | journal=J Clin Invest | year= 1990 | volume= 85 | issue= 5 | pages= 1427-35 | pmid=2332498 | doi=10.1172/JCI114587 | pmc=296588 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2332498 }} </ref><ref name="pmid8035840">{{cite journal| author=Lee JH, Arcinue E, Ross BD| title=Brief report: organic osmolytes in the brain of an infant with hypernatremia. | journal=N Engl J Med | year= 1994 | volume= 331 | issue= 7 | pages= 439-42 | pmid=8035840 | doi=10.1056/NEJM199408183310704 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8035840 }} </ref> | ||
*Irritability | *Irritability | ||
*Confusion | *Confusion | ||
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Overview
Patients with hypernatremia appear lethargic, weak and confused. However, the physical examination findings are related to the amount of volume deificit in the body and neuronal shrinkage as a result of hypertonicity. For the physical exam findings to become apparent, acute elevation in the serum sodium concentration to above 158 mEq/L is required.
Hypernatremia physical examination
Patients with hypernatremia appear lethargic, weak and confused. However, the physical examination findings are related to the amount of volume deificit in the body and neuronal shrinkage as a result of hypertonicity. For the physical exam findings to become apparent, acute elevation in the serum sodium concentration to above 158 mEq/L is required.
Appearance of the Patient
- Patients with hypernatremia appear lethargic, weak and confused. However, the physical examination findings are related to the amount of volume deificit in the body and neuronal shrinkage as a result of hypertonicity.
Vital Signs
The vital signs in hypernatremia are as follows:[1][2]
- Orthostatic blood pressure changes
- Tachycardia
Skin
- Skin examination of patients with hypernatremia is positive for:[3]
- Abnormal skin turgor
- Dry axillae
HEENT
- HEENT examination of patients with [disease name] is usually normal.
OR
- Abnormalities of the head/hair may include ___
- Evidence of trauma
- Icteric sclera
- Nystagmus
- Extra-ocular movements may be abnormal
- Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
- Ophthalmoscopic exam may be abnormal with findings of ___
- 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".)
- 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".)
- 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
- Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
Neck
- Neck examination of patients with [disease name] is usually normal.
OR
- Jugular venous distension
- Carotid bruits may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
- Lymphadenopathy (describe location, size, tenderness, mobility, and symmetry)
- Thyromegaly / thyroid nodules
- Hepatojugular reflux
Lungs
- Pulmonary examination of patients with [disease name] is usually normal.
OR
- Asymmetric chest expansion / Decreased chest expansion
- Lungs are hypo/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/absent
- Bronchophony present/absent
- Normal/reduced tactile fremitus
Heart
- Cardiovascular examination of patients with [disease name] is usually normal.
OR
- Chest tenderness upon palpation
- PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
- Heave / thrill
- Friction rub
- S1
- S2
- S3
- S4
- 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
Abdomen
- Abdominal examination of patients with hypernatremia is usually normal.
Back
- Back examination of patients with hypernatremia is usually normal.
Genitourinary
- Genitourinary examination of patients with hypernatremia is usually normal.
Neuromuscular
The neuromuscular physical exam findigs appear as a result of neuronal cell shrinkage and is positive for the following findings:[4][5][6][7]
- Irritability
- Confusion
- Nystagmus
- Lethargy
- Obtundation
- Abnormal speech
- Myoclonic jerks
- Seizures
Extremities
- Extremities examination of patients with [disease name] is usually normal.
OR
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
References
- ↑ Sterns RH (2015). "Disorders of plasma sodium--causes, consequences, and correction". N Engl J Med. 372 (1): 55–65. doi:10.1056/NEJMra1404489. PMID 25551526.
- ↑ McManus ML, Churchwell KB, Strange K (1995). "Regulation of cell volume in health and disease". N Engl J Med. 333 (19): 1260–6. doi:10.1056/NEJM199511093331906. PMID 7566004.
- ↑ Moder KG, Hurley DL (1990). "Fatal hypernatremia from exogenous salt intake: report of a case and review of the literature". Mayo Clin Proc. 65 (12): 1587–94. PMID 2255221.
- ↑ Furukawa S, Takaya A, Nakagawa T, Sakaguchi I, Nishi K (2011). "Fatal hypernatremia due to drinking a large quantity of shoyu (Japanese soy sauce)". J Forensic Leg Med. 18 (2): 91–2. doi:10.1016/j.jflm.2010.11.011. PMID 21315305.
- ↑ Heilig CW, Stromski ME, Blumenfeld JD, Lee JP, Gullans SR (1989). "Characterization of the major brain osmolytes that accumulate in salt-loaded rats". Am J Physiol. 257 (6 Pt 2): F1108–16. doi:10.1152/ajprenal.1989.257.6.F1108. PMID 2603957.
- ↑ Lien YH, Shapiro JI, Chan L (1990). "Effects of hypernatremia on organic brain osmoles". J Clin Invest. 85 (5): 1427–35. doi:10.1172/JCI114587. PMC 296588. PMID 2332498.
- ↑ Lee JH, Arcinue E, Ross BD (1994). "Brief report: organic osmolytes in the brain of an infant with hypernatremia". N Engl J Med. 331 (7): 439–42. doi:10.1056/NEJM199408183310704. PMID 8035840.