Hyponatremia physical examination: Difference between revisions
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==Overview== | ==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. | |||
==Physical Examination== | |||
Nausea and malaise are the earliest signs of hyponatremia. | |||
{| class="wikitable" | {| class="wikitable" | ||
!<big>Classification</big> | !<big>Classification</big> | ||
| Line 27: | 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''' | ||
| Line 33: | Line 22: | ||
|- | |- | ||
|'''Hypovolemic hyponatremia''' | |'''Hypovolemic hyponatremia''' | ||
|Dry mucous membrane, decreased skin turgor, hypotension (orthostatic), tachycardia | |Dry mucous membrane, decreased skin turgor, [[Orthostatic hypotension|hypotension (orthostatic)]], [[tachycardia]] | ||
|} | |} | ||
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 | ||
* | * Clinical signs of CHF, RF, | ||
* Detailed examination to detect any | * 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=== | ===Appearance of the Patient=== | ||
*Patients with | *Patients with hyponatremia may appear with wide range of presentations from no discomfort to severe distress. | ||
===Vital Signs=== | ===Vital Signs=== | ||
| Line 56: | Line 41: | ||
*[[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 | *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 | * Skin examination of patients with hyponatremia varies depend on the underlying causes like hypothyroidism, CHF, adrenal insufficiency | ||
*[[Cyanosis]] | *[[Cyanosis]] | ||
*[[Jaundice]] | *[[Jaundice]] | ||
| Line 68: | Line 53: | ||
* Bruises | * Bruises | ||
===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 | |||
* 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 | *[[Weber test]] may be abnormal | ||
*[[Rinne test]] may be positive | *[[Rinne test]] may be positive | ||
* 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 | * Neck examination of patients with hyponatremia may lead to other causes like tumors | ||
*[[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 105: | Line 79: | ||
===Lungs=== | ===Lungs=== | ||
* Pulmonary examination of patients with | * Pulmonary examination of patients with severe hyponatremia | ||
* Asymmetric chest expansion / Decreased chest expansion | * Asymmetric chest expansion / Decreased chest expansion | ||
*Lungs | *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 114: | 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 | *[[Egophony]] present may be present | ||
*[[Bronchophony]] present | *[[Bronchophony]] present may be present | ||
* | *Reduced [[tactile fremitus]] may be present | ||
===Heart=== | ===Heart=== | ||
* Cardiovascular examination of patients with | * Cardiovascular examination of patients with hyponatremia | ||
*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 130: | 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]] | *A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] may be heard . | ||
===Abdomen=== | ===Abdomen=== | ||
*[[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 145: | Line 116: | ||
===Back=== | ===Back=== | ||
*Point tenderness over vertebrae | |||
*Point tenderness over | |||
*Sacral edema | *Sacral edema | ||
*Costovertebral angle tenderness bilaterally/unilaterally | *Costovertebral angle tenderness bilaterally/unilaterally | ||
| Line 153: | Line 122: | ||
===Genitourinary=== | ===Genitourinary=== | ||
*A pelvic/adnexal mass may be palpated | *A pelvic/adnexal mass may be palpated | ||
*Inflamed mucosa | *Inflamed mucosa | ||
===Neuromuscular=== | ===Neuromuscular=== | ||
*Patient can be oriented to persons, place, and time | |||
*Patient | |||
* Altered mental status | * Altered mental status | ||
* Glasgow coma scale | * Glasgow coma scale has to be checked | ||
* 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 | ||
* | * 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 | *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 | ||
===Extremities=== | ===Extremities=== | ||
*[[Clubbing]] | *[[Clubbing]] | ||
*[[Cyanosis]] | *[[Cyanosis]] | ||
Latest revision as of 20:38, 2 July 2021
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Hyponatremia Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Hyponatremia physical examination On the Web |
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American Roentgen Ray Society Images of Hyponatremia physical examination |
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Risk calculators and risk factors for Hyponatremia physical examination |
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
- 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