Is This Patient Hypovolemic?

Abstract

In each of the following clinical scenarios, clinicians need to identify which physical signs reliably and accurately indicate volume depletion or dehydration. Case 1A 54-year-old man, taking ibuprofen for knee arthritis, presents with a 1-day history of melena. Physical examination reveals a pulse of 80/min and blood pressure (BP) of 140/82 mm Hg when supine, and 115 and 132/86 mm Hg when standing. There ismildepigastrictendernessandhemoccultpositive stool. The hematocrit is 0.39. Case 2A 62-year-old woman has 6 months of episodic vertigo and unilateral hearing loss, attributed to Ménière disease. She begins treatment with hydrochlorothiazide, but during a follow-up visit 3 weeks later, she reports her dizziness is slightly worse since starting the medication. Her heart rate is 80/min and BP is 160/84 mm Hg when supine, 88 and 134/72 mm Hg when standing. She experiences slight dizziness when standing. Case 3An 82-year-old nursing home resident presents to the emergency department with a 1-day history of nausea and vomiting. Her underlying medical problems include dementia, coronary artery disease, atrial fibrillation, emphysema, and hypertension. She has been treated with aspirin, isosorbide dinitrate, furosemide, bagonist inhalers, and lisinopril. The clinician diagnoses viral gastroenteritis or food poisoning because other members of the nursing home have an identical illness. On examination, the patient is afebrile, alert, and demonstrates normal speech and strength. Her mental status is no different from her baseline. The pulse is 75/min and the BP is 154/90 mm Hg supine, and 90 and 130/76 mm Hg when upright. The tongue, mucous membranes, and axillae are moist. Results of an examination of the heart, lungs, and abdomen and an electrocardiogram are normal. WHY IS CLINICAL EXAMINATION IMPORTANT?The term volume depletion describes the loss of sodium from the extracellular space (intravascular and interstitial fluid) that occurs after gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis.

Retrospective analysis of inferior vena cava collapsibility with point of care ultrasound and urine sodium and FENa in patients with early stage acute kidney injury

“…Determining volume status in patients relies mostly on history and physical examination findings. However the evidence for using conventional methods is weak [9]. In previous studies physical signs including poor skin turgor, postural variation in blood pressure and heart rate, and dry oral mucosa were unable to accurately predict the volume status [10–12].…”

Anamnese, exame clínico e exames complementares como testes diagnósticos

“…Os objetivos dessa série de artigos foram buscar a identificação dos achados de anamnese e exame físico que são úteis ou inúteis baseados na qualidade da evidência clínica, além de estimular novas pesquisas na área. Essa série de artigos do JAMA ainda continua embora com uma frequência de publicação mais baixa sendo publicados dois artigos em 2013, avaliou, a luz das melhores evidências, vários dados de anamnese e manobras do exame físico incluindo uma avaliação baseada em evidências das lombalgias, da esplenomegalia, da palpação do fígado, da pressão venosa central, do melanoma, do infarto do miocárdio, do aneurisma de aorta abdominal, da hipovolemia, da regurgitação aórtica, da meningite aguda, do câncer de mama, do baqueteamento de dedos, da síndrome do túnel do carpo e da lesão de ligamentos do joelho, entre outros temas [10][11][12][13][14][15][16][17][18][19][20][21][22] . Além dessa série do JAMA, outros autores têm publicado artigos avaliando de forma científica a arte da anamnese e do exame físico em várias áreas médicas, mas ainda são poucos os estudos nessa área [23][24][25][26][27][28][29][30][31] .…”

Re-examining examination: misconceptions in clinical medicine

“…10 In true acute hypovolaemia, the most valuable observation is either a postural rise in pulse of at Journal of the Royal Society of Medicine least 30 bpm or postural dizziness so severe that it is impossible to complete the test. These criteria give a sensitivity of 97% and a specificity of 96% for acute blood loss of greater than 630 mL.…”