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Examination of fluid status

Examination of fluid status for medical student finals, OSCEs and MRCP PACES

  • The point of this examination is to determine whether the patient is:
    • Hypovolaemic (underfilled / dry)
    • Euvolaemic (well-filled)
    • Overfilled (overloaded)
  • This is one of the most common examinations performed by doctors (often subconsciously) so is becoming more common in exam situations

 

Introduction

  • Wash your hands
  • Introduce yourself
  • Identity of patient – confirm
  • Permission (consent and explain examination)
  • Position at 45°
  • Expose chest to waist

 

General Inspection

  • Patient
    • Well or unwell
    • Suggestion of overload
      • Short of breath (high respiratory rate); oedema
    • Suggestion of underfilling
      • Sunken skin
  • Around bed
    • General (can be associated with under- or overfilling)
      • Catheter
      • NG tube (may be due to vomiting so hint at underfilling)
    • Fluid in
      • IV fluids (if so, type and rate – e.g. 0.9% saline with 20mmol KCL over 4 hours) – suggests underfilling
      • Infusions (e.g. furosemide or GTN) – suggests overload being treated
    • Fluids out
      • Drains
      • Vomit bowels
  • Charts
    • Observations
    • Fluid balance chart
    • Drug chart (especially diuretics and iv fluids)

 

Hands and arms

  • Temperature (fever increases insensible losses making underfilling more likely)
  • Pulse: volume and rate
    • Tachycardia may suggest underfilling
    • Though note can also be due to many other factors, commonly pain and fever, less commonly tachyarrhythmia and hyperthyroidism. Click here for details on tachcardia.
  • Blood pressure lying and standing (postural blood pressure)
    • A postural BP drop of over 20mmHg may suggest underfilling
    • Though can be due to low vascular tone (e.g. old age, beta-blockade or autonomic neuropathy)

 

Head and Neck

  • Eyes: sunken (underfilling)
  • Mouth: dry mucous membranes (underfilling)
  • JVP: raised in overload, not visible (even with patient lying flat) if very dry

 

Chest

  • Sternum
    • Capillary refill (if over 2 seconds centrally may suggest underfilling)
  • Palpation
    • Apex beat (if displaced can suggest overload)
  • Auscultation
    • Heart (3rd heart sound in overload)
    • Lung bases (pulmonary oedema in overload)

 

Abdomen

  • Ascites
    • Though this is excess fluid, oedema is usually associated with intravascular depletion (i.e. patient hypovolaemic)

 

Legs

  • Peripheral oedema (in overload)

 

To complete exam

  • Thank patient and ensure they’re comfortable
  • Do they need help getting dressed?
  • Wash hands
  • Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
    • Take a full history
    • Bedside investigations
      • Obs: resp rate, pulse, BP, O2 sats, temperature
      • Measure lying and standing BP (if not already done)
      • Look at the fluid balance chart (if not already done)
      • Daily weights (if overloaded and giving diuretics)
    • Further investigations
      • Bloods
        • U&E – raised creatinine (acute kidney injury may suggest underfilling)
        • Lactate (high lactate may suggest underfilling)
        • Consider BNP (raised in heart failure)
      • Echocardiogram (to confirm heart failure)

 

Click here for examination of nutritional status and click here for other clinical examinations