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All right, everybody, welcome back to another episode of the space learning series.

I'm Jack Penner, an internal medicine resident at UCSF, and I'm thrilled to be here joining my good friend, Charmine, Dan, and our salon.

We got a real treat today.

We're all going to be the overnight admitting resident when we get a page from the ED saying that there's a 48-year-old woman who's here with a sodium of 113. I got to say, I get pretty excited when I see hyponatremia. What about you all? I was literally telling my wards team that this is my dream admission. Like, I'm praying to the admitting gods to get like a hyponitriumicase like this.

Wow, guys.

I'm personally more of a hypercalcemia type of guy, but, you know, teach their own.

I have no space for you in my life, R.C.

Sodium or butt?

I am going to stay out of this. Yeah.

Say, before we get into a fight, can someone share their approach with hypernatum

so we're all on the same page.

And Dan, Jack, please contain your excitement, okay?

Sure, me, I'm going to do my best, but I'm a sodium, sodium guy for sure.

Anyway, guys, I can't believe it was so long ago, but it was our second episode where we released the hyponotremia schema.

It just blows my mind.

Anyway, just to get started, you know, when approaching a patient with hyponotremia, you know, I think we're often taught to think about the serum osmolity first.

Because you can have like hypoosmolar, and that's like the majority of hyponotremia we're going to talk about in this episode. But you can also have u-osmolar like you might see with pseudohypenetremia from hyperlipidemia or like a paraprotein. and also hyperosmolar hyponitremia,

like you might see with hyperglycemia.

And I bet we've all had that case of DCA where the sodium seemed surreptitiously low. Anyway, while we don't generally need to send this serum osum on all patients, sometimes it's going to be obvious. It can often be helpful if the diagnosis is uncertain or when we're going to be entertaining some of these causes of pseudo hyponitremia. But once we feel confident that we're in hypolomolar hyponotremia land, that's when things really start getting interesting. I don't know about a lot of our listeners, but, you know, when I was in med school, I was taught to, first start by breaking it down by volume status and ask,

is this hypovolemic, uvalemic, or hypervalemic hyponitremia? But I personally kind of have a hard time determining somebody's intravascular volume status, unless it's, like, pretty much at the extremes of the spectrum. Like, if they have four plus putting edema to their belly button, I feel pretty good about that.

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