Date:
Patient:
MRN:
Clinician: (Emergency Physician, Hospitalist, Sports Medicine Physician)
Reason for Visit:
Altered mental status following exercise (confusion, lethargy, seizure)
Nausea, vomiting, headache after exercise
Evaluation for hyponatremia
History of Present Illness:
Briefly describe the presentation:
Symptoms following exercise event (type, duration, intensity)
Time course of symptom onset
Volume of fluids consumed during exercise
Past Medical History:
Include any relevant past medical conditions, such as:
History of electrolyte imbalances
Underlying cardiac or renal disease
Use of diuretics or other medications that affect electrolytes
Social History:
Exercise habits (frequency, intensity, acclimatization)
Recent fluid intake patterns (including excessive water consumption)
Physical Exam:
General: Appearance of illness, hydration status (skin turgor), mental status
Vital Signs: Temperature, pulse, blood pressure
Labs:
Serum sodium concentration (hyponatremia is diagnosed when serum sodium < 135 mEq/L)
Consider mentioning other electrolytes (potassium, chloride) and serum osmolality.
Imaging:
Imaging studies are not typically needed for diagnosis but may be performed to rule out other causes of altered mental status (head CT).
Assessment:
Diagnose exercise-associated hyponatremia based on clinical presentation, history of exercise, and hyponatremia.
Assess the severity of hyponatremia based on serum sodium level and symptoms.
Plan:
Outline the treatment plan based on severity of hyponatremia:
Mild hyponatremia (sodium > 130 mEq/L): Oral fluid restriction may be sufficient.
Moderate hyponatremia (sodium 125-130 mEq/L with some symptoms): Intravenous (IV) fluids with normal saline may be administered cautiously.
Severe hyponatremia (sodium < 125 mEq/L or severe symptoms): Hospitalization and close monitoring with IV fluids and possible diuretics (in specific situations) are necessary.
Advise on appropriate fluid replacement strategies for future exercise events.
Prognosis:
Briefly discuss the prognosis, which is generally good with prompt treatment of mild or moderate hyponatremia. Severe hyponatremia can have serious neurological complications.
Education:
Document any education provided to the patient regarding:
Importance of adequate hydration during exercise
Risks of excessive water consumption during exercise
Warning signs and symptoms of hyponatremia
Notes:
Include any additional relevant information not covered above, such as the need for follow-up labs or referrals to a sports medicine physician for exercise guidance.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.