Hyponatremia diagnostic study of choice

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Diagnostic Study of Choice

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Case #1

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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

  • The page name should be "[Disease name] diagnostic study ", with only the first letter of the title capitalized. Note that the page is called "Diagnostic study of choice."
  • Goal:
    • To describe the most efficient/sensitive/specific test that is utilized for diagnosis of [disease name].
    • To describe the gold standard test for the diagnosis of [disease name].
    • To describe the diagnostic criteria, which may be based on clinical findings, physical exam signs, pathological findings, lab findings, findings on imaging, or even findings that exclude other diseases.
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  • Remember to follow the same format and capitalization of letters as outlined in the template below.
  • You should include the name of the disease in the first sentence of every subsection.


Template statements

flame photometer or an ion selective, electrode that requires sample dilution before assay [1] .

Gold standard/Study of choice:

  • [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
  • The following result of [gold standard test] is confirmatory of [disease name]:
    • Result 1
    • Result 2
  • The [name of the investigation] should be performed when:
    • The patient presented with symptoms/signs 1. 2, 3.
    • A positive [test] is detected in the patient.
  • [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
  • The diagnostic study of choice for [disease name] is [name of the investigation].
  • There is no single diagnostic study of choice for the diagnosis of [disease name].
  • There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
  • [Disease name] is mainly diagnosed based on clinical presentation.
  • Investigations:
    • Among patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
    • Among patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
    • Among patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.

The comparison table for diagnostic studies of choice for [disease name]

Sensitivity Specificity
Test 1 ...%
Test 2 ...%

✔= The best test based on the feature

Diagnostic results

The following result of [investigation name] is confirmatory of [disease name]:

  • Result 1
  • Result 2
Sequence of Diagnostic Studies

The [name of investigation] should be performed when:

  • The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
  • A positive [test] is detected in the patient, to confirm the diagnosis.

Biochemical evaluation for finding the etiologies of hyponatremia :

The unnamed parameter 2= is no longer supported. Please see the documentation for {{columns-list}}.
2

Diagnostic Approach to Hyponatremia

 
 
 
 
 
 
 
Serum sodium < 135 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Psuedohyponatremia
• Check for hyperglycemia
• Check for hyperproteinemia
• Check for hyperlipidemia
• Check for other solutes in serum
• Check for sign of Jaundice
• Check for history of operation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure serum Osmolality
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low < 280 momol/kg
 
 
 
 
 
 
 
Normal or High
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypotonic Hyponatremia
 
 
 
 
 
 
 
Isoosmolar or Hyperosmolar hyponatremia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Low GFR
• History of Thiazide use
 
 
 
 
 
 
 
 
• Post TURP or hysteroscopy (Glycine, Sorbitol)
• Direct sodium by direct potentiometry if normal measure total protein and lipid
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Yes
 
• Renal failure
• Thiazide induce hyponatremia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients with edema
(pulmonary, peripheral), ascites
 
 
 
Signs and Symptoms of hypovolemia
(↓ BP, Orthostatic hypotension)
 
 
 
 
 
 
 
Heart failure
Cirrhosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Less < 25 mEq/L
Hypovolemic Hyponatremia
• Extra renal loss
Gastrointestinal losses, Diuretics, Third space losses
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure urine sodium and serum osmolality
 
 
 
 
Measure urine sodium
 
 
25 to 40 mEq/L
• Infuse Isotonic saline 1 liter over 1 hour
• Remeasure urine sodium
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine osmolality<100
 
 
 
 
 
 
 
 
 
 
Hight > 40 mEq/L
Hypovolemic Hyponatremia
• Renal loss
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
No
 
Urine osmolality measured After therapy initiated
 
Yes
 
 
 
Use of diuretics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recovery from one of the followings:
• Mild hypovolemia(Patients given isotonic fluids
• Hypopituitarism
(Patients given glucocorticoids))
 
 
 
Low cortisol, Positive ACTH stimulation
Primary adrenal insufficiency
 
 
 
Urine sodium> 40 mEq/L
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Head injury/surgery
Cerebral-salt wasting
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with rapid water consumption
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ensure that sodium intake > 150 mEq/L over next 24 hours (infuse 1 liter of isotonic fluid over one or more hour)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Remeasure urine osmolality and sodium
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High-fluid, low-protein diet including:
• Beer potomania
• Tea and toast diet
 
Water intoxication:
• Psychosis
• Endurance activity(Marathone)
• Ecstasy use
 
 
 
 
 
Urine Na >40 or
Urine osm > 100
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine Na < 40 or
Urine osmo< 100
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypovolemic Hyponatremia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check for Glucocorticoid deficiency with
Cortisol level and ACTH stimulationand
hypothyroidism with TSH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
check morning cortisol and
ACTH stimulation test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Glucocorticoid deficiency
 
Elevated TSH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SIAD
Nephrogenic SIAD
Reset Osmostat
 
Severe Hypothyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate underlying etiology
 
 
 
 
 
 
 
 
 


  • Here you should describe the details of the diagnostic criteria.
  • Always mention the name of the criteria/definition you are about to list (e.g. modified Duke criteria for the diagnosis of endocarditis / 3rd universal definition of MI) and cite the primary source of where this criteria/definition is found.
  • Although not necessary, it is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.
  • Be very clear as to the number of criteria (or threshold) that needs to be met out of the total number of criteria.
  • Distinguish criteria based on their nature (e.g. clinical criteria / pathological criteria/ imaging criteria) before discussing them in details.
  • To view an example (endocarditis diagnostic criteria), click here
  • If relevant, add additional information that might help the reader distinguish various criteria or the evolution of criteria (e.g. original criteria vs. modified criteria).
  • You may also add information about the sensitivity and specificity of the criteria, the pre-test probability, and other figures that may help the reader understand how valuable the criteria are clinically.
  • [Disease name] is mainly diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
  • There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
  • The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
  • The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
  • [Disease name] may be diagnosed at any time if one or more of the following criteria are met:
    • Criteria 1
    • Criteria 2
    • Criteria 3

IF there are clear, established diagnostic criteria:

  • The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
  • The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
  • The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

IF there are no established diagnostic criteria: 

  • There are no established criteria for the diagnosis of [disease name].

References

  1. Hussain, Iram; Ahmad, Zahid; Garg, Abhimanyu (2015). "Extreme hypercholesterolemia presenting with pseudohyponatremia - a case report and review of the literature". Journal of Clinical Lipidology. 9 (2): 260–264. doi:10.1016/j.jacl.2014.11.007. ISSN 1933-2874.

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