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.
