Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: This section may be blank or contain nonspecific complaints depending on the severity of hypernatremia.
Thirst (most common symptom)
Dry mouth
Fatigue, weakness
Confusion, delirium (in severe cases)
Seizures (in severe cases)
History of Present Illness:
Onset, duration, and severity of symptoms
Recent hospitalizations or emergency department visits
Changes in urination (frequency, amount)
Level of consciousness (confusion, lethargy)
Recent illnesses causing fluid loss (diarrhea, vomiting, fever)
Diuretic use (prescription or over-the-counter)
Past Medical History:
Underlying medical conditions that can contribute to hypernatremia (diabetes insipidus, chronic kidney disease, congestive heart failure)
History of hypernatremia
Prior surgeries or procedures
Medications (current and recent) – including diuretics, laxatives
Family History:
Family history of kidney disease (not typically relevant for hypernatremia, but may be helpful for overall risk assessment)
Social History:
Recent heat exposure or strenuous activity (can increase sweating and fluid loss)
Alcohol or illicit drug use (can worsen dehydration)
Mental status (confusion, dementia) – may increase risk of dehydration due to impaired thirst sensation
Physical Examination:
Vital signs (blood pressure, heart rate, temperature) – may be abnormal in severe hypernatremia
General appearance (dry mucous membranes, lethargy)
Neurologic exam (mental status, reflexes) – may show confusion, agitation, or seizures
Skin turgor (poor skin turgor indicates dehydration)
Laboratory Tests:
Serum sodium level (confirmed diagnosis)
Electrolytes (may show abnormalities like low potassium)
Kidney function tests (creatinine, BUN) – to assess kidney function
Blood osmolality (may be elevated in hypernatremia)
Urinalysis (may be concentrated with hypernatremia)
Imaging Studies:
Imaging studies are not typically used for hypernatremia diagnosis unless kidney function tests suggest further investigation is needed (e.g., ultrasound for kidney stones).
Diagnosis:
Hypernatremia (confirmed by elevated serum sodium level)
Severity of hypernatremia (based on serum sodium level and clinical presentation)
Underlying cause of hypernatremia (if identified)
Treatment Plan:
Treatment depends on the severity of hypernatremia and the presence of symptoms.
Intravenous fluids (isotonic or hypotonic solutions) are the mainstay of treatment for rehydration.
Rate of fluid correction should be carefully monitored to avoid overcorrection which can cause seizures.
Addressing the underlying cause of hypernatremia (e.g., stopping diuretics, treating diabetes insipidus)
Prognosis:
Discuss the outlook based on the severity of hypernatremia, the underlying cause, and response to treatment.
Early diagnosis and treatment are crucial to prevent serious complications like seizures and coma.
Patient Education:
Importance of staying hydrated, especially in hot weather or during exercise
Following fluid restriction recommendations if medically advised
Importance of medication adherence (including avoiding diuretics unless prescribed)
Warning signs of worsening hypernatremia (increased thirst, dry mouth, confusion)
Importance of regular follow-up to monitor sodium levels and adjust treatment as needed
Next Follow-up:
Schedule for the next appointment depends on the severity of hypernatremia and response to treatment.
Close monitoring of sodium levels is essential until they are normalized.
Regular follow-up to monitor for recurrence and manage underlying condition.