Simplified Hyponatremia Workup for New Nurse Practitioners
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Show notes:
I saw a meme recently that compared hyponatremia to folding a fitted sheet— you can watch a million videos on how to do it but you're probably going to crumple it up and hope you never have to deal with it. 🤯
Luckily in primary care, low sodium is easier to deal with outpatient, and doesn't have to be super complicated.
In today's video I'll be talking about low sodium, one of the top abnormal labs in primary care.
Hyponatremia involves understanding kidney function, but I've broken it down the simplest, clearest, most digestible way to give you the most helpful insight to take into your practice.
I'll bring you through the steps for the vast majority of patients you'll see, and if you need to go down the rabbit hole of workup further what we go into in this video, you'll have the tools to do so.
Workup for Low Sodium in Primary Care
You'll learn:
How to know when your patients needs to go to the ER, and when you can work them up outpatient
The simplest way to remember low sodium
The #1 lab you should always think of when you see low sodium
How to know if your patient needs IV fluid (or if that'd be the worst possible thing to do for them)
QUICK NOTE: I made an error in the algorithm slide #2 (25:22 timestamp), serum uric acid is going to be LOW in SIADH and HIGHER in states of fluid overload (CHF, etc). So the opposite of what I say on that slide. So sorry about that!
Lab Interpretation Crash Course
If you liked this episode, it's a sneak preview of how we cover labs inside our comprehensive Lab Interpretation Crash Course. It covers CBC, CMP, Urinalysis, Dipstick & Microscopy, TSH, Lipids & top Endocrine labs in primary care, and comes with lifetime access and continuing education credits! Check it out here.
Resources mentioned in this episode:
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WEBVTT
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Hey there. Welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable and take the best care of their patients. If you're looking
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for clinical pearls and practice tips without the fluff, you're in the right place. Make
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sure you subscribe and leave a review so you won't miss an episode. Plus, you'll find
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links to all the episodes with extra goodies over at realworldnp.com slash podcast.
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So in this week's episode, I'm going to be talking about the diagnostic approach
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to diagnosing and managing hyponatremia using a case study. This is for adults
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in primary care. And I know this can be a really mind bending topic. I actually used to
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really hate lab interpretation as a new nurse practitioner. And when I started Real World NP
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about two years ago, the first thing I did was do a deep dive into labs because I felt like
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even after about three and a half years of practice, I was still kind of like hacking my
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way through lab interpretation and it still really stressed me out. So I actually ended up
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making an entire course about lab interpretation and primary care for adults called the lab
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interpretation crash course for nurse practitioners. So if you are struggling with lab interpretation,
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definitely, definitely check that out. It's covered CBC, CMP, urinalysis, TSH, lipids,
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and the top endocrine labs in primary care. And it really like just putting that together
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from me myself, like made me go from despising lab interpretation to like actually loving it,
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feeling so confident that I actually enjoy looking at labs now, which is just such a different place
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than I used to be. So anyway, in this week's episode, it's kind of like a sneak preview of
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the way that I talk about labs inside the crash course using a case study specifically
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for hyponatremia. So I'll be covering the diagnostic approach, those first steps to make,
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and then the kind of later steps for the more complex case situations. But I have to
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say, if you're a patient of primary care, you can get away with just the first couple of steps,
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and then it will give you your more or less a clear diagnosis and next steps going forward. So
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it can be a little bit of a mind bender, but I'll walk you through it. So hopefully you can
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feel a lot more confident understanding hyponatremia and where to go next for each
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of the next steps. So the patient I'm going to be talking about today is all the patient
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information, personal health information, PHI has been changed. So it's not his real name
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or details. So this patient is named Jim. He's 61 years old. He is a cis male patient.
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And when I saw him, he was there to reestablish care with a new PCP. I was a new grad at the
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time and there was a physician that had left and I had absorbed their panel of patients at
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the federally qualified health center that I was working at the time. And this patient hadn't
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been seen in about a year, I believe, if I remember correctly. But yeah, so the chief
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complaint was that quote, I don't do what I'm supposed to do. Which I, you know,
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I appreciate that honesty. I appreciate the transparency there. He said that he does take
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his blood pressure medications. I'll talk about his PMH in a second. He does take
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blood pressure medications. He drinks a six pack of beer every day and smokes one pack
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a day, approximately for the last 50 years. He drinks a little bit less than eight ounces
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of water per day, which is painful to just think about. And also he said he's not interested in
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cutting down or quitting either his alcohol use or tobacco use. So what is his past medical
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history? He has a past medical history of hypertension, emphysema, alcohol use disorder,
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as well as a past remote history of diverticulosis, no instances of diverticulitis.
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He has no past surgical history or family history that he knows of. In terms of
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medications, he's just taking chlorothaladone 50 milligrams a day. That's PO, oral. At the time
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of the visit, his blood pressure was 144 over 80, so slightly high. Heart rate of 100, also
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slightly high. Oxygen of 98%, which is normal. A BMI of 24, which is just within the expected
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range. And he was saying that he was going on a quote unquote drinking weekend this weekend
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with his friends. So I'm going to stop there and talk about the plan. So in this episode,
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I'm specifically focusing on the hyponatremia aspect, but clearly each patient in front of
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you is a whole person that has holistic care necessary for their complete wellness, right?
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But I don't want this to be a super sprawling episode, so I'm really going to narrow in
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on hyponatremia. But at the end, I'm going to touch on some of the other components of
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his holistic care. Okay. So at that visit, I decided to check some labs. So whenever I check
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labs, I try really hard to either choose them based on a guideline that has been established,
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whether it's USPSTF or another health guidance body that you're following,
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or the medical conditions in front of you, right? Because I think that a lot of us,
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especially new grads, are looking for the guidance of when to order labs and when not to.
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I think that the go-to for most clinicians, whether they're brand new or experienced,
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is to just order labs just because to do some screening. But anyway, I wouldn't worry about
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it too much if you're a brand new grad. I think it's more important to choose the safest
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option than to split hairs if you're not quite sure, right? So anyway, I checked some
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labs for him. I checked his CBC and a CMP. And the intention for those labs for this
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particular patient, I really want to check on his renal function because he hasn't been seen in a
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year and he takes diuretics for hypertension. For the CBC, I'm concerned about his alcohol use
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disorder. So I want to see if there's any of those anemia changes because of the fact that
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he is drinking consistently every single day alcohol and not really taking in that much
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water. And I'm not quite sure of his nutritional status. I also checked a TSH,
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a lipid profile, and a hemoglobin A1C. The hemoglobin A1C and the lipids were a little
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bit borderline in terms of the guidelines. There should be screening lipids for patients,
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according to USPSTF, over the age of 45 for cis male patients. And then hemoglobin A1C
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and TSH, I think I was just feeling uncomfortable at the time and so I ordered those labs. I
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don't really have a great reason to order the TSH at that juncture. And the hemoglobin A1C,
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his BMI was 24, which was in the expected range. But just as a general screening lab,
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because I wasn't clear about his nutritional status, that was the decision-making that I had
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behind that. But anyway, I want to talk about the lab results. Clearly there's more to this
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patient than just labs, but we're talking about labs in this episode. So let's jump to
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that. So his CBC was luckily normal and his lipid panel was also normal. His hemoglobin
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A1C was also within the normal range, so that was great. So that leaves the CMP.
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So the notable ones, so complete metabolic panel, both has the basic metabolic panel as
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well as function tests. And so the main ones to write home about were his TSH,
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which was 5.77. Actually, sorry, that's not part of the CMP, but that was like that extra
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lab that I ordered. And it actually was slightly elevated. And the units that I'm
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using are US standard units. If you're outside of the US, there are international units and
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you can just use conversions to translate those. But the TSH was 5.77, so that was
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slightly high. When it comes to the complete metabolic panel, the main labs that were
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abnormal were a sodium of 134, which is low. And the reference range for the lab that
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I was using was 137 to 145 was the normal reference range. And that again is in US units.
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And one thing I want to say about labs is that there is kind of a gold standard,
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typical expected reference range, but then you actually also have to look at the lab
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that is in front of you because they're tools that they're using to actually compute
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the labs is dependent on that machine and the reagents that they're using. So anyway,
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use the reference range of your lab. But the reference range for this lab was showing that
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it was 134, which is low. The other abnormal labs are a potassium of 3.3, which is slightly low
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for that lab reference range, which is about 3.5 to 5.3. The other thing is the chloride
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was low at 92 and the reference range there is 98 to 110. So all of these were on the slightly
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lower side. The liver function tests, the LFT panel, those were all completely normal.
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The only other thing that I want to add in the conversation about sodium is that the glucose
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was normal, 94, so within that normal reference range. The BUN and the creatinine and the GFR
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were also in the normal reference range, as is the carbon dioxide. But that's a conversation
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for another day. You can definitely join us in the lab crash course if you want to talk
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about carbon dioxide. I'm like obsessed. Anyway, so let's talk. So those are the lab results.
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So I want to jump just like pause in those lab results. We'll come back to that, but I want
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to talk like at the core about hyponatremia. And the take home that I want you to think
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about when it comes to hyponatremia is that what's actually happening, it's not about the
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salt. It's actually about the water. When you see low sodium, think about the water that
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we're actually holding onto more water than we are getting rid of. I think that's like one of
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really hard things. I think a lot of us think, oh, low sodium will just add some salt back into
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their diet and it will be fine. And it's a lot more complex than that, which I'll talk about,
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the physiology. It's a little bit mind bending, but hopefully I can really simplify it for you.
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So three things. So that's number one, hyponatremia. We're holding onto more water
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than we're getting rid of. And so why does that happen? So there's three things to
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think about next. Number one, it's related to the inherent function of the kidneys as well
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as the status of the kidneys. Like do they have kidney injury or is it normally functioning?
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And then it just ties back into how the kidneys actually work, which I'll tell you all
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about, I promise. So just hold that thought. So number one is about how the kidneys work
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and if they are functioning optimally or not. The second thing is about intake of salt and
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water. And then the third thing is about ADH and whether it's working or it's not working.
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So that's a lot of information to take in, but that's just to prime you so that I'm going to,
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I'm going to talk, I'll talk you through all the steps. Don't worry. Okay. So just keeping
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those in the back of your mind, kidneys, intake of salt and water and ADH. I'll come
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back to that. But when it comes to the workup of hyponatremia, the first thing to think
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about, again, keeping in mind all the things that I've told you to keep in mind so far,
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but like, I guess I want to pause there and say with lab interpretation, I try to make an algorithm
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as best as I can in terms of what are the knee jerk next step responses to those labs.
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So when I see low sodium, number one, more water than we can get rid of. And then the
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second thought is, is this truly low? Because there are a number of labs where there can be a
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high. And that is certainly the case with low sodium. So is it truly low? So thinking about
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water and then thinking about, is it truly low? So what do I mean by that? So glucose
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can artificially lower the sodium level. So there's something called a sodium correction
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score. You can just straight up Google that. I use the one from MD Calc. I'm not an
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affiliate of them. I just enjoy their tools, but glucose can artificially lower sodium. And
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makes sense if you think about the pathophys of osmolality, which is a little, again,
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getting a little bit into the mind bending thing, but basically sodium is a marker of how
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concentrated the blood is. So when you have high glucose, the blood is getting a lot more
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concentrated. And so reflexively the sodium can go down to make sure that it is not too
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concentrated. So when you use that calculation score and you take into account the glucose
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being high, it will calculate what the kind of true sodium level is and see if there's
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actually a sodium problem or if the sodium is just doing a really great job trying to
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keep your serum from getting too concentrated, right? So that's the first kind of tricky
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thing is like sodium, okay, we're talking about water and what is the glucose? Like
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kind of like step one, automatic first next step. The other thing to keep in mind in terms
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of a false reading, high lipids and high protein can alter the like machine's ability to read the
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sample correctly. So the actual like machine that processes all of the blood samples.
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So those are the three kind of like false reasons that you can have low sodium glucose,
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which you can do a correction score for lipids and protein. There's no correction
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score. You just take that into account when you see it being high. And apparently also
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jaundiced patients, it can cause some false hyponatremia, but I don't really have any other
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information aside from that. And I've actually never come across that before. Typically,
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if you have a jaundiced patient, you have a lot on your plate to be managing.
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And so hyponatremia is like part of that picture, but it's not like the predominant
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thing that you're worried about in jaundice patients anyway. So that's like a longer story
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to get into, but keep it at that. Okay. So when you're looking at, again, I'm doing a
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lot to keep in your mind, especially if you're more of a visual person. I'm more of a visual
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person. So anyway, low sodium holding onto a lot of water. Is it truly low thinking about glucose,
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lipids and protein and jaundice patients? The next thing is how low are we talking?
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So again, when it comes to lab interpretation, my personal practice is that I have those knee
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neck steps that I kind of like mentally tie them together. So glucose and sodium go together in
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my mind. And then the next thing is about when to worry, like when to freak out,
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when to send them to the ER, when to send them to a specialist, when to worry.
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That's how I do the lab course. But also in this podcast episode is kind of covering that
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reference range. So how low is it? Okay. So the normal reference range, and again, apologies
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if you're outside of the United States, I'm way more savvy with the US standard units compared
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to the international units, but you can just literally do a conversion where you plug those
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numbers in and the same thing applies. So the normal reference range, again,
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depends on your lab that you're looking at, but it's about 135 to 145. So the red flag,
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when to freak out and like don't actually freak out, but you know, the place to like
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really worry with low sodium is 130, less than 130. And, or if they have symptoms,
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those patients need to go to the ER. In the real world, there are some,
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some exceptions. However, I never manage a patient less than 130 without collaborating
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with my supervisor or colleagues. There are some cases, very rare cases, but especially
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if you are a new grad, do not manage those patients by yourself. So if it's less than
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130 and, or they have symptoms, those patients typically need to go to the ER.
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So what are the symptoms that we want to watch out for? So mild symptoms can be things like
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headache, fatigue, lethargy, nausea, vomiting, dizziness, gait disturbances,
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confusion, and muscle cramps. So that sounds like a lot of things to memorize,
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but the really kind of like narrowed down simple thing is that the main side effect
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of low sodium is brain swelling. So it goes back to what I said about the concentration and
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osmolality. If the serum becomes too dilute, you know, with the isotonic and hypertonic
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and hypotonic, if you go back to that kind of like refresher or patho stuff,
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then you can remember that when it becomes imbalanced, you can either get shrinking or
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swelling. And so when it comes to hyponatremia, low sodium means high water, and then that
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can cause brain swelling. So that really ties very nicely into the symptoms that you're looking out
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for. What neurological symptoms are we looking out for there? Severe symptoms with hyponatremia
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are seizures, coma, and respiratory arrest. That's very rarely happened in primary care.
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And if you have somebody having a seizure in front of you, they need to go to the ER.
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We likely already know that, right? Most of the time, patients will have symptoms if the
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hyponatremia is prolonged. So it's been more than 48 hours. And if it's less than 129, most likely
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they're going to have symptoms at that point. And then when in terms of the pragmatism here,
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in primary care, if they don't, you're kind of first assessing, do they have those symptoms?
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Number one. And then number two, you can utilize all of those symptoms to explain
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to patients what they're looking out for in terms of those alarm signs and symptoms as
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you're working the patient up, if they're above 130. So I have some more things to say about that,
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but let's just recap. So again, hyponatremia, is it truly low? How low are we talking here?
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Again, 130 is that definite red flag to kind of memorize. And then you definitely want to
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address anything that's out of the reference range. And then the next, I want to come back
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to what I said at the very beginning. What are the next steps from there? The next steps are
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thinking about those three things, kidneys, intake of salt and water, and then ADH,
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whether it's working or not. So I'm going to circle back with that. I want to talk about,
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I want to draw on the patient now. So for this patient, if we go back to the lab results
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that I shared, his sodium was 134, which was lower than that reference range. His glucose
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was normal. His kidney function was also normal. He had no symptoms. Basically what happens with
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lab interpretation, a lot of new grads tend to freak out, as I did, and that's totally normal.
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I think that we need to differentiate. Did the person have symptoms at the time of the
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visit or did they have no symptoms and you just found it incidentally? And so that right
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there can help you calm down a little bit. But yeah, basically when I got those labs back,
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called the patient, either myself or the nursing staff that I worked with, called the patient to
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ask specifically, do they have any symptoms? Does he have any symptoms of the neurological
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variety that I shared? And he did not. So the next steps are, aside from calling him,
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asking about symptoms are to think about those three things, the kidneys, the salt water
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intake, and ADH. And I advised, number one, the symptoms to watch out for. The next thing
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was about low sodium precautions. So because we understand that it's because the water intake is
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high and maybe the salt intake is low. But again, I'll talk about that more in a second.
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The general advice to start as we're getting to work looking at the potential causes is to say,
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just limiting the water intake, like limiting that for his case, limiting the alcohol intake
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is actually more optimal than the water intake, if that makes sense. Again, I'll talk about
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this more in a second. And the next very quick first step when you see that for a patient is
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doing a medication check. So the top medications that can cause low sodium are thiazides,
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SSRIs, anti-seizure medications, sulfonylureas, opioids, and ecstasy. But hopefully in your
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history you've asked about recreational drug use at that time, MDMA. But anyway,
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those are the first steps. Contact him, ask about his symptoms, advise on potentially,
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if he can. He's not interested really in cutting back on his alcohol intake,
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which he's already shared with us. But you can have that conversation of like, you know what,
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there's actually something not quite normal with your labs and it would be optimal if you
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could cut back in these next days and have a conversation about that. But anyway,
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let's talk about those three underlying causes aside from medications. That's a quick first
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thing to think about. And then the next are the kidneys intake of salt and water and ADH.
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So let's talk about kidneys. I love this stuff. Hopefully you love this too. I think understanding
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it really helps you to not just straight up memorize, but when you get it, it's just,
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it sinks in a little bit more. So when it comes to the kidneys, how they actually work
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at optimal status is that there's a set rate of concentration. So the urine that comes out of
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kidneys has a minimum dilution and a maximum dilution, meaning that if you take in a ton of
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water, even though your body has too much water inside, your body cannot like urinate straight
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water. It just doesn't work like that. The kidneys do not work that way. So they always
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have some sort of solute in the urine. So as you can see, if you have an excessive amount
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of liquid in your body, like that water fluid and not enough solute to get rid of it, it's just
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going to take the solute that we actually need to compensate for that. So the sodium is going
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down because we're getting rid of some of it and we're holding onto too much water.
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And it's actually, it's a weight-based calculation of each individual's
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minimum and maximum dilution. So for example, if you have an, in this hyponatremia example
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with like too much water in your body, it's never going to be straight water in the urine.
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And similarly, you can never urinate straight solute. And so even if someone is dehydrated,
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it's going to, the kidneys are going to pull water, even though if it's not the best
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thing for the body, if that makes sense. The other thing to keep in mind is that
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hyponatremia can happen if somebody's kidneys are not functioning optimally.
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So in the case of ESRD, end-stage renal disease, if they're not voiding, then we're holding onto
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extra fluid. And then the other side, are we taking in too much fluid like water intoxication?
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So which really kind of ties into the point number two, talking about dietary intake of
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water slash salt. So again, people think that automatically, oh, hyponatremia, let's just add
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back, but it's a little bit more complex than that. So the three kind of main
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reasons why we'd have too much water in the diet. And I think this is so fascinating
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beer potamania. I don't know if that's like the, the, the term that we're still using.
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That's what I learned about in nursing school a while back, but basically when somebody has
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alcohol use disorder or they are having excessive amounts of alcohol during the day
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they're not eating enough solute or eating enough meals. And their primary diet is from
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the alcohol itself. What actually happens is it's alcohol is really carbohydrates and water.
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And so when you break down carbohydrates, it gets broken down into water. So you're
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basically just, you have a straight up water diet with very limited solute.
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So especially in this patient's case, he potentially is drinking so much alcohol and not
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in his diet to balance it out that it's actually a lot more water in his diet because of the
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carbohydrates being processed into water. I find that super fascinating. I love that kind of
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stuff. But anyway, there's two other potential causes of dietary intake of water slash salt.
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Is this like tea and toast diet that you've probably heard of where it's sort of like a,
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just a state of malnutrition where somebody is only having, again, carbohydrates and fluid.
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And when there's just carbohydrates in a person's diet and there's not enough protein or fat or
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other solutes, it just gets broken down into water. So you have way too much water.
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And then even if your kidneys are working appropriately, like I said,
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there's a maximum dilution to the point where they're not like your body is just not going
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to void straight water. And so it's going to start pulling the solutes that your body
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actually needs to be able to continue to void. The third piece about the dietary is the
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polydipsia where either someone has a compulsion to drink extra water or they are drinking
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excessive water in like a hazing ritual or something like that. If there's like a take
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home about salts, like don't just add salt tabs. You basically never add salt tabs. When
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somebody has hyponatremia, you have to get to the root cause. And if you understand it,
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it's a lot easier. So the last piece in terms of the etiologies of hyponatremia,
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talked about baseline kidney function and how it cannot get rid of extra water because of the
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limitations of the inherent function of the kidney. Plus if you add any renal dysfunction
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on top of that, it's going to do an even poorer job of getting rid of extra water.
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The second thing is about dietary intake of water slash salt, but it's really about the
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water and carbohydrates more than it is about salt. And then the third piece to keep in mind
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it comes to low sodium is ADH, antidiuretic hormone. And this is a little bit of a throwback
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to like the core courses that we've taken for nurse practitioner programs and nursing programs.
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But ADH is antidiuretic hormone and that's confusing. I love listening to the Curbsiders
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podcast and there's a physician on there, Joel Toth, who's a nephrologist and I'm really
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obsessed. He's just so brilliant. And he talks about ADH as as hydration hormone.
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It's not actually the real name, but if it keeps it straight in your mind,
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hopefully that will be helpful, right? So that comes from our brain telling our body to hold
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onto water in states of volume depletion. So this is where it gets a little bit confusing.
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If you're not already confused, hopefully this is clear enough. But in low perfusion states
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heart failure, cirrhosis, the kidneys are not getting perfused. So what happens is that your
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body thinks that it actually needs more volume, which equals more water. And it tells your body
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to make more ADH to add more hydration so that the kidneys are being perfused. However,
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so if we're talking about the balance of the body is saying, oh my gosh, there's way too
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water and not enough sodium, the kidneys are saying, no, we aren't getting enough hydration
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so that they're holding onto extra water. And so when it comes to that ADH, ADH always wins.
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It wins over sodium. So this is a maladaptive response. Your body's the body is trying to
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help, but it's a maladaptive thing because it's actually worsening the hyponatremia.
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Yeah, so it's technically doing its job, but it's maladaptive, if that makes sense.
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The other piece of ADH is that there are certain cases of abnormal ADH function. These are zebra
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diagnoses, right? This is adrenal insufficiency, hypothyroidism and SIADH. And this is not for
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you to like memorize. This is just to have like a baseline kind of understanding. And
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probably you're going to have to listen to this a couple of different times because
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it's really mind bending. It's a lot to keep track of. So I'm going to tie this all
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together. So let's just recap again, a couple of different recaps here. So steps to low sodium
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management, right? So we talked about how low sodium is actually a lot of water. There's kind
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of three buckets of main causes in addition to medications, but the way that the kidney
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functions, the dietary intake of water and salt. And then the third thing is about ADH.
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And then when it comes to how you manage it, you want to see how low it actually is
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in terms of those when to worry thresholds and the symptoms to watch out for. So kind of step
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one is that safety piece of like, okay, how low are we talking? Do they have symptoms? Are they
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okay for us to work them up or do they need to be seen in the ER? The next step is you get
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to work identifying what's causing it in the first place. And then the treatment is holding
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water and adding salt. So I'll talk about that in a second. I already said a couple of
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times that you don't want to add salt. So just stick with me for a second. I want to
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actually have this as a case study on the YouTube channel. So if you want to look at the algorithm,
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also, again, it's inside the lab crash course, all of these algorithms and printouts that you
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can keep at your desk. But if you want to just look at it visually, definitely go to
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the YouTube channel for the hyponatremia case study. So I'm going to go through the
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algorithm of workup. If you have a patient who has a sodium of less than 130 and they're
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symptomatic, those patients go to the ER. If you have a patient, if they are not symptomatic,
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if it's between 130 and 135 with no symptoms, step number one is look at glucose, lipids,
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protein, and their kidney function, right? Because those are the false low reasons. So
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high glucose, high lipids, high protein can cause falsely low sodium. But then you also
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want to look at the renal function. Again, those are the kind of first two knee-jerk reactions of
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what is the glucose, what is the creatinine and BON and GFR so that you can take the next steps
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and verify if it's actually true hyponatremia. So if you don't have any of those things to
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start, the first next step is looking at the medication list. Like I said, the thiazides,
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SSRIs, anti-seizure medications, et cetera. And then you also want to order a serum
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osmolality. So serum osmolality, again, is talking about the actual concentration of the blood.
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Basically, this is like another second check to see if it's actually true hyponatremia
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or if it's just fake, right? If it's just because of something else in the blood that's
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throwing off that lab. So if you have a normal serum osmolality, it's not true
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hyponatremia. So in that case, if you haven't already checked the lipids and the protein,
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check those, right? However, if the serum osmolality is low, so it's dilute, the serum
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is dilute because there's too much water. It's actually considered to be true hyponatremia.
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The next step is to order a urine osmolality. So urine osmolality is looking at the
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concentration of the urine. And this is, I think this gets really confusing, but if you
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think about it, if you have a lot of water in your body, your kidneys are going to try
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hardest to maximally dilute the urine. So the osmolality, the concentration is going to be low
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because there's going to be a ton of water in the urine. So that is telling us that it is not
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related to ADH, right? I want to step back for a second, just a refresher about the ADH thing.
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So ADH is going to be triggered in that maladaptive state like cirrhosis or
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volume depletion, heart failure, things like that, because the kidneys aren't getting enough
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perfusion. And so if your serum is low, if your concentration of your serum is low,
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your urine should also be low because your body should be trying to get rid of
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the extra water. But if it's not, then it's telling you that the ADH is doing something
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funky. Whether or not it's trying really hard to restore perfusion to the kidneys,
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or if it's something like SIADH, the syndrome of inappropriate ADH, right? So that's your branch
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point of like, if you get a urine osmolality, urine concentration, if the urine concentration
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osmolality is low, it's not related to ADH. And that's like your branch point.
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If the concentration of the urine is high when it really should be low, right? Because
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your kidneys should be getting rid of extra water, then there's something going on with
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And I want to pause here and say that this is super confusing. So if you're confused,
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that's totally normal. And most of the time in primary care, you will stop here and you won't
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even actually need to order urine osmolality because you will get your answer in the first
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steps. So yeah, so step two is if this rarely happens, especially as a new grad.
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Okay, so step number two, I mean, it's not really step two, but part two,
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you likely won't get to this place. However, if you do, I highly recommend you get either
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your supervisor or a colleague involved, because these are number one, potentially zebra diagnoses,
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or they are more medically complex patients that are more likely at high risk of something
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going wrong quicker, right? So if you get to that place of determining that there is
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potentially a problem with ADH, meaning that the urine osmolality is actually high,
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the concentration, the urine is very concentrated when it really shouldn't be,
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there's likely an ADH problem. And so the next kind of segmented options are,
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is this a maladaptive ADH problem with volume depletion? Again, meaning somebody who has
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volume depletion because of CHF or cirrhosis or lack of perfusion to the kidneys for any
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body is going to try to hold on to extra water with ADH despite there being too much water already,
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right? Versus are we in a situation of like SIADH where it's inappropriate antidiuretic hormone?
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So the first thing, the first kind of branch point that helps you figure that out is doing
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the physical exam. So you want to see if they have symptoms of either number one volume
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depletion or overload, right? And, and trying to see like, is there a risk there with heart
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failure, right? And so just being really cautious that you're not confusing heart failure with
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volume depletion. Like, again, this is why we're tapping in somebody else to make sure
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we're on the right track, right? But just looking at that physical exam, is there any
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reason that they're volume depleted versus is there a perfusion related problem? Do they have,
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jugular vein distension? Do they have low extremity edema? Do they have crackles in their lungs?
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Like looking at that piece. The next step you theoretically would do, again, I do recommend
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having somebody involved tagged in if you're going to be taking these next steps, but the
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next steps that you can look at are ordering a uric acid level as well as the urine sodium
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level. However, this is getting a little bit into the weeds. So I'm really not going to
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acid. Basically that is a potential branch point for it to help you further distinguish
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if this is an SADH potential related problem versus a volume depletion or a lack of
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perfusion related problem. So if you ordered a uric acid level, if it was normal or if it was
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on the higher side, that is more likely to be on that CHF, you know, or volume depletion
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side, lack of perfusion side versus if that uric acid level is low, then it's more likely
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to be SIEDH type of picture, right? But anyway, going back to physical exam for a second,
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the most accurate thing when it comes to assessing volume status from a physical
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exam perspective, the main most reliable pieces are looking at orthostatic vital
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signs, pedal edema, jugular vein distension. Dry mucous membranes are not always reliable
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as a measure. Apparently dry axilla is supposed to be one of the most reliable physical exams
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to assess volume status, but like, I don't think anyone I know has ever assessed that. I have not,
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certainly. So anyway, FYI, but anyway, like the point here that I want to share great
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information here. So you feel like you've seen the end of the road basically of like where
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primary care ends and where a specialist potentially begins. However, like this kind of
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like second part to part of the algorithmic workup really doesn't, number one doesn't
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happen that often. And number two really needs to have somebody else involved. I know
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I've said that like three times, but please do. I think the reason I say that is based on my own
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experience and the NPs that I work with, I constantly felt the need to prove myself
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to myself that I could do it, number one, and also to my colleagues, my patients,
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my supervisor. I just was so, I was just so consumed with imposter syndrome that I would
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do a lot of things that were from a proving place, coming from a place of proving myself.
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And so I just, I would just want to acknowledge you and recognize that you might be in that
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place too. And also safety is always number one, right? And there is a lot of, you know,
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being very humble in the first year of nurse practitioner practice. So no one really,
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no one would expect you as a new grad or even as an experienced provider to be
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doing the second kind of half of that hyponatremia workup, just FYI.
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So anyway, let's circle back to the case. So Jim, in terms of the management,
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number one, you want to look at the other labs, right? Cause we really only talked
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about sodium today, but he's a whole person with a lot of things that we need to address.
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So just to go back to his labs real quick, the main abnormal labs that were there,
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there was a TSH that was slightly high, sodium was low, potassium was slightly low,
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and then the chloride was also low. Pearl of practice there, the chloride for the most part,
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unless we're talking about acid and balance disturbances, you really don't care as much
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about the chloride if the sodium is low. If the sodium is low, then it's really just
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correlating with the sodium. But anyway, so you want to look at the other labs and address
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those, the low potassium, the slightly high TSH. I have an episode with a TSH interpretation
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with hypothyroidism with high TSH. If you haven't listened to that one already,
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definitely go back and do that. I wanted to reconcile his medications to kind of just make
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sure we were all on the same page. I wanted to talk about the different lifestyle factors
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might be contributing to his hyponatremia. So in terms of the med reconciliation, he was only
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taking chlorothaladone. So that is potentially a risk factor for him with the low sodium
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in addition to the alcohol intake. So having a discussion again, he said at the beginning of
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the visit, he's not interested in cutting back on the alcohol use, but we're still going to
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have a conversation about it. I'm going to say, hey, Jim, I know you said that you
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weren't interested in changing either the alcohol or the tobacco, but just so you know,
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here is this, you know, this medical problem that's happening and is likely related to that.
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However, because of the chlorothaladone, I actually chose to stop that as his only
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hypertensive agent and change to lysinopril 10 milligrams. He had normal renal function.
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He's never taken it before. Just a pearl of practice here. Chlorothaladone is one of the
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thiazide diuretics and hydrochlorothiazide is the one we all like learn about and talk
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about as much. It sounds like chlorothaladone is having more of a moment now than it was a
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couple of years ago, but it actually has better evidence for morbidity and mortality protection
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than hydrochlorothiazide. It's very potent though. So that's probably the rationale for
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choosing that first, the hydrochlorothiazide, according to the GNC8 guidelines. So I stopped
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that. I changed to lysinopril, which is another one of the first line antihypertensive
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agents. And then what I chose to do is also recheck his labs in a few days. Also a fun
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clinical pearl about chlorothaladone is that it can lower the potassium level over time.
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The body should be able to compensate for that. And you can tell that in the first three weeks
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of taking it, but if their potassium is persistently low, then you either need to add
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that supplement on or take them off the medication. So anyway, not to get too off
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track there, but his potassium was low. So hopefully stopping the chlorothaladone will
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help with that. Adding lysinopril will potentially also help with that. And then
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with him changing his intake of alcohol will help with the hyponatremia globally.
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And so I just decided to recheck his labs in a few days. There were no alarm signs and symptoms.
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It was not at that danger zone of less than 130. He was feeling totally fine.
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I did ask him to take it easy with the alcohol going away on the weekend with his
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buddies because that is potentially very dangerous. And who knows whether or not he
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listened to me. So that's pretty much it for his management in terms of the labs,
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that management piece. When I rechecked his labs, the potassium had normalized and sodium
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had normalized, which was beautiful. Lovely little mini intervention of changing one medicine.
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And then it seemed to work. I also, in terms of holistic care, just to recap on the other
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parts of his care is I ordered a total T3 and a free T4 to evaluate that high TSH level.
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Again, there's another episode that talks about high TSH if you want to check that out.
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I added folic acid and thiamine for his consistent alcohol use. And who knows if he decided to
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continue to take it. I had him do a nurse visit in about one to two weeks to do a blood
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pressure check because I changed one of his blood pressure medications and it was also
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slightly high that day. And then I did another follow-up with me, the provider,
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in about three months. And so the choice there in terms of hypertension management in our
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the workflow is that the nurses can do a sole visit by themselves to check the blood pressure,
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do medication counseling. And if any adjustments need to be made, then they tag in one of the
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providers, either myself or another colleague on site. So yeah, so I scheduled the follow-up
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for about three months, but I could have done sooner if the blood pressure was still high
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at the next visit. But yeah, the blood pressure and just to address also in the first visit,
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again, like a little pearl of practice for new nurse practitioners or newer clinicians
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is that his blood pressure was high in the visit. And I think it's very uncomfortable
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for us as providers, especially when we're new to see something that needs, quote unquote,
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fixing in front of us or addressing in front of us. And we want to do all the things right
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away. However, the real world is that we have to balance patient rapport, patient preference,
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right? And this was my choice, is that the person in front of me already has told me that I take
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my hypertensive medications, but I don't really do what I'm supposed to. And so for me to jump
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right in and address his blood pressure, you know, address like a whole bunch of things
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at like one visit, I ended up eventually changing the chlorothaladone. But at that
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visit, I just left it as is because I wanted to, number one, get more information, but also
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develop this rapport with him over time. I addressed it in my notes saying blood pressure
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is high today, patient states that he is not interested in changing his medications,
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you know, because I had a conversation with him about that. And so at the very least,
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I've addressed it, even if I haven't made that specific change on that visit. And that's
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a clinical judgment piece and a philosophy of practice piece. But that's just like one of
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the recap points I wanted to make about this particular case study and that holistic perspective
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outside of solely just hyponatremia.
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That's our episode for today. Thank you so much for listening. Make sure you subscribe,
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leave a review and tell all your NP friends so together we can help as many
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nurse practitioners as possible give the best care to their patients.
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00:43:51.460 --> 00:43:55.680
If you haven't gotten your copy of the ultimate resource guide for the new NP,
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head over to real world and p.com slash guide. You'll get these episodes sent straight to your
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share anywhere else. Thank you so much again for listening. Take care and talk soon.
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