Hyponatremia physical examination

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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

• Nausea and malaise are the earliest signs of hyponatremia.

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

• Cyanosis
• Jaundice
• Pallor
• Bruises

• Description (Adapted from Dermatology Atlas)
  Description (Adapted from Dermatology Atlas)
• 
  Description (Adapted from Dermatology Atlas)

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

• 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 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

• Chest tenderness upon palpation may be present
• 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 may be heard .

Abdomen

• Abdominal distention
• Abdominal tenderness in the right/left upper/lower abdominal quadrant
• Rebound tenderness (positive Blumberg sign)
• A palpable abdominal mass in the right/left upper/lower abdominal quadrant
• Guarding may be present
• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test

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