What Causes Low Sodium? Hyponatremia Workup (Lab Interpretation for New Nurse Practitioners)

[@nicolechen6769]

I'm not a brand new np but still find your vedioes very helpful. Thank you

[@RealWorldNP]

So nice of you

[@matthewpixley4941]

Two years ago my sodium dropped from 134 level for 3 years, to 102. I was admitted to ICU and stayed for 4 days. I’m now 132 and doing much better. I couldn’t walk for 1 week after getting released from the hospital. I had some neurological issues with speaking and balance for a year afterwards. Glad to be ok now.

[@RealWorldNP]

Thank you for sharing. This is why it is so important to monitor and intervene.

[@tseringwachungtsang4874]

Thank you, Liz for your wonderful videos. You are an awesome provider. You are compassionate and have a great passion to teach and share. I wish I could have you as my mentor.

[@RealWorldNP]

That's very kind of you, and thank you!

[@urgentcaredr]

I’ve been watching your videos for a few weeks and they are so helpful. You are humble and knowledgeable. Love how you break down concepts and I love the case studies. I’m a NP student in my last year. Wish I had all your knowledge. Thank you!

[@RealWorldNP]

I appreciate your kind words - good luck in your last year - you got this!!!

[@urgentcaredr]

@@RealWorldNP thank you. Do you do mentoring?

[@RealWorldNP]

@@urgentcaredr We are planning to offer more mentoring in the new year - get on our email list and you'll get notified! www.realworldnp.com/guide

[@lat0021]

These are really good! Please keep them coming!

[@RealWorldNP]

Thank you! I'm so glad!

[@kentaro6022]

You're a great teacher. Thank you for your videos.

[@RealWorldNP]

You are very welcome

[@GabriellaVillegas-s2i]

Well recently, I got sick with cramping vomiting that lasted me almost 5 days I was in bad shape, but thank God I have gotten better and my doctor did my bloodwork and told me I had low sodium not sure if it’s from drinking too much water or not adding enough salt in my diet I wouldn’t eat a lot of salt because I try to watch my blood pressure but I didn’t know it could lead to this.

[@RealWorldNP]

I am glad you are doing better.

[@lupullum7356]

Great informative video, made a lot of sense, Thank You

[@RealWorldNP]

Glad it was helpful!

[@Sofiahansen_3069]

thank you for very informative video. what is the impact of SSRIs ?

[@RealWorldNP]

SSRI’s can cause hyponatremia within weeks of starting medication.

[@Esthersky11]

Thank you! Excellent video!

[@RealWorldNP]

Glad it was helpful!

[@shaleenas9147]

Hi! All of the references I’ve been reading (up to date and AAFP) mention that your acid levels are low and SIADH. However, you mention in your video that serum uric acid levels are high in SIADH. Can you clarify this?

[@RealWorldNP]

Hey Sarah, thank you SO much for that catch, I put it in backwards, you're right. Lower uric acid in SIADH because of increased excretion. I'll make a note about that below the video! Thank you again.

[@TheShiro1208]

Thank you so much for posting this. It's very informative.

[@RealWorldNP]

You're so welcome!! It's SUCH a tough topic.

[@Dju7c]

This was great thank you

[@RealWorldNP]

You are so welcome!

[@benjaminlew7003]

Hi, Liz - I came across this insightful video after a search on hyponatremia. I have a question about when to go to the E.R. If someone receives a sodium value of less than 130 in an outpatient PCP setting, is it always required to go to the E.R. for a recheck (as you discuss at the 7-min:30-sec mark)? Would rechecking via non-E.R. means ever be appropriate (such as returning to the PCP)?

[@RealWorldNP]

Thanks so much for watching. Unfortunately for safety and liability reasons, I can't answer specific cases here, but it's a complicated answer. I'm familar with VERY rare cases that can be assessed closely outpatient but this has been under strict guidance of a nephrologist and due to a known diagnosis, managed by renal and in a collaboration with a nephrologist & PCP. We talk more about specific patient cases inside the Lab Crash Course, though, if you want to join us there and ask inside the community (www.realworldnp.com/labs).

[@TwoTakeTommy]

Can over training possibly cause this combined with over hydrating + stimulants? Can it possibly cause nueropathy in feet and hands?

[@RealWorldNP]

I'm not familiar with neuropathy being related, it's typically limited to neurologic symptoms. Water intoxication can definitely cause hyponatremia, but I'm not sure about stimulant use!

[@TwoTakeTommy]

@@RealWorldNP thanks :)

[@bernadettejones2491]

@@TwoTakeTommy go to Dr Eric berg and Dr Stan both are holistic functional drs there both very good they are better than western drs

[@bernadettejones2491]

@@TwoTakeTommy Dr Eric berg and Dr Stan both on u tube

[@marybodenheimer851]

I enjoyed this video on hyponatremia. Would you please share the calculation (or where to find it) which you adjusted sodium level with an elevated glucose level.

[@RealWorldNP]

Absolutely! MDcalc is a great app to keep all the calculators in! Here's the link to that website (also app): www.mdcalc.com/sodium-correction-hyperglycemia

[@claytonrogers9290]

Do you have a resource for switching from one BP med to another in terms of equivalency? Also I think I’ve asked if you have a method of triage when you’re deciding which lab abnormalities to tackle first?

[@RealWorldNP]

Hm, I don't think I have a list like that! I'll keep an eye out certainly. For labs, I think the more I learn about them, I realize the more nuanced and complex they are. I think they really inform each other, and looking at the worst case scenario for each of them individually-- so like low sodium, what's the worst case scenario compared to a high glucose, and then try to triage that way. Sometimes it adds up to multiple, severe abnormalities that need to go to the ER instead of primary care. So it depends! I have a lab interpretation course going live in January if you want to learn more about ALL the labs (well, CBC, BMP, LFTs, cholesterol) in primary care! I'll post more as it comes closer!

[@claytonrogers9290]

Real World NP I would love more info about the lab interpretation course!

[@vetoef]

GFR of 32ml/min normal? Um no. I think his eGFR is actually over 100ml/min with Scr of 0.8. So correct statements but slide is incorrect... GREAT VIDEO! Really difficult topic and explained VERY WELL! RBDNP

[@RealWorldNP]

Oh no!! Thank you so much for pointing that out!! Total typo, I don't know WHAT happened there, totally wrong. I may end up re-recording this, since I also mistakenly said SIADH had high uric acid (should say low) 🤦‍♀️ (I noted that in the description but I"m worried people won't see it). Thanks so much!! Hyponatremia breaks my brain!!

[@SkopeeProductions]

Subscribed, thank you so much!

[@RealWorldNP]

You're very welcome!!

[@jegreen4227]

This was very useful information! i do have a question: I have always understood that drinking beer or alcohol would lead to dehydration, which could lead to hypernatremia, right? but in this case study, this man who is hardly drinking water and having a 6 pack of beer every day has hyponatremia. Can you help me think this through? could he actually have been in a state of hypernatremia if it weren't for the Chlorthalidone??

[@RealWorldNP]

Totally, sodium is so confusing. When patients are predominantly subsisting on alcohol without enough solutes in their diet, it's metabolized into CO2 and water, and since the kidneys can't excrete urine past a certain dilution/solute level, it leads to hyponatremia from too much water backlogged and needing to be excreted (but it's more dilute than the kidneys are able to make urine since there's a set amount of dilution that the urine can be-- it'll never be straight water). But in some cases alcohol use can lead to dehydration in cases where patients aren't able to drink enough water. But the body responds to water replacement well generally speaking, since the risk of imbalance of sodium in the serum is brain swelling. Does that make sense?

[@AmitThakorlovemeorhateme]

about 2 months back i started taking cranberry capsules because i though it would help me clear any uti infection if i had. i was already peeing more than usual before this but for the past 2 months i had been taking these cranberry capsules which caused me a lot of frequent urination and it would be like a sudden urge. i was already very conscious with my salt intake and I go to run daily but for the past 2 months i had noticed sudden swelling of my cheeks which i couldnt understand. i drink over 4 liters of water daily. yesterday i got my blood test and i saw my sodium at 134, a year back i had sodium at 141, 138 in april and now 134. chloride also is low at 95. i dont know if this sudden puffiness of these cheeks in past 2 months will go away or not. really worried. help

[@RealWorldNP]

Hi Amit - I can't advise you personally on this because I am not your primary care provider and there are many legal and safety issues that arise from giving advice over KZbin. I think it's best for you to consult with your primary care provider - the person who knows your history and has seen you in person. Good luck!

[@alextalarico7765]

Hi Liz! Great lecture as always! I apologize if I simply missed this... Based on your algorithm, what would the next step be (from a family practice NP perspective) once you discover that the urine osmol is high and that the cause is likely ADH-related? Is there further workup we should do in primary care or would you refer? And if referral is warranted, would that be under the umbrella of endocrinology or nephrology? Thank you as always for your awesome content!

[@RealWorldNP]

Alex, if the provider suspects ADH related endocrinology referral is usually the best route. You could also call the endocrinologist and ask if they prefer you to draw any additional labs prior to appointment.

[@alextalarico7765]

Thank you! I appreciate all you do for the NP community!

[@bigsamtheevangelist5122]

Not sure if it's okay to ask here but just trying to figure out what's going on with me. Had abdominal pain and should pain which seemed like gallbladder problems but it wasn't and ultrasound checked out normal. Looking at my blood results my sodium is at134, Glucose 98 after fasting 8 hours, protein is at 8.0. Is this signs of Hyponatremia? also had diarrhea issues the day before. I do drink sweet tea a lot sometimes so not sure if thats anything?

[@RealWorldNP]

Hi Sam - I appreciate you reaching out, but for legal and safety reasons I can't advise on your case. I always refer people back to their primary care provider who knows your history and your treatment plan. I do wish you the very best!

[@russellm7530]

I ended up in the ER recently because of low sodium levels. I guess I was drinking too much water. I was drinking up to 2 gallons a day sometimes more. My level was below 130. Could I just continue drinking the same amount of water and just take some salt throughout the day? Or do the other electrolytes and other minerals/vitamins etc need replaced also. They said to just cut down on the water to no more than 5 of the plastic hospital drinking mugs per day. Great video.Thank you.

[@RealWorldNP]

Thank you so much for watching and I hope it was helpful! For legal and safety reasons I can’t advise on your personal case, and I always recommend you refer back to your primary care provider who is familiar with your history.

[@ccxfrank109]

i started at 113 now im at 125(this is what my doctor said) and he wants me to get right about 130

[@RealWorldNP]

Good! Remember to continue to coordinate with your provider for next steps.

[@JesusMartinez-Editor]

Thank you! Great explanation

[@RealWorldNP]

Glad it was helpful!

[@hannahbnanalovesyou]

Can stimulant medications cause low sodium? My sodium has been 134 since starting adderall xr. I’ve never had a problem before starting it. My kidney labs have come back normal and my doctor isn’t sure what’s causing it. I don’t drink more than two liters of water a day

[@RealWorldNP]

Hi Hannah - I am so sorry, but for legal and safety reasons (i.e. it could jeopardize my license) I can't advise on your case. Maybe there is another doctor who could help?

[@ChandraPalGupta]

Good lecture. Please try to be at slow speed.

[@RealWorldNP]

Hi Chandra Thanks for watching. KZbin does allow you to slow down the videos :)

[@seacoast4950]

I heard there is a type of hyponatremia where you can’t replace the sodium by eating more sodium/salt, but instead you have to get the sodium through an IV. Would that be in cases of CHF and cirrhosis to correct the perfusion problem?

[@RealWorldNP]

Yeah most of the time you can't replace the sodium with salt tablets, it really depends on the underlying condition. For some sodium levels, you need closed monitoring in the hospital and IV replacement.

[@footstepsforTheLordMostHigh]

Is drinking milk going to help with that other version of hyponatremia?

[@brentnearhood8874]

Thanks! Some of your presentation was a little fast and the words ran together. Hard to understand.

[@RealWorldNP]

Hi! I've gotten slower as I've made more videos - in the future, there is a gear at the bottom right of the video, click on that, and you can slow down the video to 3/4 or 1/2 speed. Hope that helps!

[@patriciamilford8943]

Is there a place that you hide these great algorithms?

[@RealWorldNP]

They're all hiding in Up to Date, Epocrates, AAFP... :) All adapted, of course. HOWEVER!! I do have my lab slides available inside the Lab Interpretation Crash Course if you want to join us :) opens again in late spring. Realworldnp.com/labs

[@patriciamilford8943]

@@RealWorldNP I'm in it right now :) GREAT course! I'll have to go hunting for these! Thank you!

[@RealWorldNP]

@@patriciamilford8943 😊😊😊

[@veronica7751]

Thanks

[@RealWorldNP]

You're welcome!

[@estee233]

So you don't think that Lisinopril would increase his risk of hyponatremia. ACE inhibitors can bring it on from the literature.

[@RealWorldNP]

I agree, there is a risk for hypo-natremia with each patient especially when multiple co-morbidities come into play.

[@ericmiles6413]

JIM SOUNDS LIKE ME... SAME CURRENT ISSUES.

[@RealWorldNP]

Hopefully you are working through this with you provider.