# *** Hyponatremia [symptomatic; acute vs. chronic >48 hours; mild 130-134, moderate 120-129, severe
# *** Hyponatremia [symptomatic; acute vs. chronic >48 hours; mild 130-134, moderate 120-129, severe <120] Checklist -- ABCs: if severe (<120) or symptomatic, page renal and consider ICU due to need for close monitoring and frequent lab draws -- Chart Check: baseline Na, medication use -- Admission Criteria: *** no strict criteria -- HPI Intake: diet, alcohol, meds, co-morbidities including CHF, cirrhosis, ESRD, cancer -- Can't Miss: *** EtOH use, seizure risk, rapid overcorrection -- Admission Orders: *** serum Osm, Urine Osm, Urine Na, strict I/O's, BNP if evidence of CHF; fluids vs diuretics -- Initial Treatment to Consider: if severe with symptoms - immediate hypertonic (3%) saline 100mL bolus over 10 mins to get Na up 4-6 points Assessment: -- History: *** meds, diet, EtoH use, hx of CHF, cirrhosis, CKD, cancer, endocrine disorder -- Clinical: *** seizure, N/V, weakness -- Exam: *** AMS, weakness, volume exam -- Data: *** Na, Serum Osm, Urine Osm, Urine Na (SOsm <300 if hypotonic, UOsm >100 if ADH present, UNa <30 if RAAS active) -- Etiology/DDx: *** hypovolemia, decreased effective circulating volume (3rd spacing), SIADH (infection, malignancy, meds, primary brain injury or lesion), ESRD, primary polydipsia, low solute Working Through The Differential: Is this hypotonic hyponatremia? (SOsm <300) - if not, "pseudohyponatremia" from hyperglycemia, protein Is ADH present? (UOsm > 100) - if not, primary psychogenic polydipsia, tea and toast, beer potomania Is RAAS On? (UNa <30) - if yes, hypovolemia or 3rd spacing 2/2 CHF or cirrhosis; if no, salt wasting via SIADH, diuretic use, ESRD, or endocrine etiology The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***. Plan: Workup -- Serum Osm, Urine Osm, Urine Na -- if unclear etiology, can also send TSH, lipid screen, SPEP/UPEP, serum cortisol and ACTH, UDS, BNP -- BMP q *** Treatment -- Correction Goal: *** at a rate of 4-6 per 24 hours -- Volume: *** (IVF vs diuresis) Severe with Sxs - 3% NaCl 100mL bolus over 10 min (to Na raise 1-3) given up to 3x to get Na up 4-6; Severe without Sxs - 3% Na Cl drip until Na >125; Otherwise, volume repletion by exam -- if ADH Absent - restrict fluids, slow introduction of solute; high risk of overcorrection -- if ADH on, RAAS Active - replete if hypovolemic, diuresis if CHF, nephrotic syndrome -- if ADH on, RAAS Off - likely SIADH, restrict 0.8L/day, salt tabs 1g TID; consider Lasix, vaptans
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