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The Hydration Status Examination DR AMY ROSS (FY2)OSCE EXAMINATION– what is expected Hypo/Eu/Hypervolaemia Hyponataemia GAIN Guidelines Orthostatic Hypotension GENERAL INSPECTION – SIGNS FOCUSED EXAM FURTHER INVESTIGATIONSOSCE examination- hints and tips Always be aware of surroundings! Most likely will have fluid balance chart and device to test Blood pressure with… Understand difference of what clinical signs indicate which fluid balance status.. Be familiar with HYPONATRAEMIA GAIN GUIDELINESOSCE CHECK LIST - https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist- Hydration-Status-Assessment.pdfIntroduction 1. Wash hands 2. Introduce yourself to the patient 3. Confirm the patient’s name and date of birth. 4. Briefly explainwhat the examination will involve 5. Gain consent 6. Position the patient on the bed, with the head of the bed at45°. Important - ** ask patient if they are in any pain prior to examining ** End of the bed examination What clinical signs would you be looking to comment on following general inspection in hydration status examination?Possible scenarios where increase in fluid requirements might be present.. Trauma Febrile illness and sepsis Burns Surgical patients may need additional volume secondary space fluid losses.ge and third- Gastrointesdiarrhoea)es (e.g. vomiting, PolyuriaGeneral Inspection General Inspection– Are they on IVF? Do they have fluid balance Underfilled? chart Is the any accurately/correctly Euvolaemic? wounds or drains Overfilled? Pitting from surgery? filled in? UO, ?NEWS oedema ?Bleeding CHART ? BP stable ?Diarrhoea Medications ?fluid restriction Does the patient appear breathless ?NG or have increased ?Alert and tube/stoma Pillows work of breathing? orientated /vomit bowel +++Systematic approach – Hands and arms Skin Turgor – increased or decreased? Any pitting oedema? Heart rate Blood pressure Postural Drop Temperature of hand(sever increases quantity of insensible losses)Capillary Refill Apply five seconds of pressure to the distal phalanx of one of a patient’s fingers and then release. In healthy patients, the initial pallor of area compressed should return to its normal colour in less than 2-3 seconds. >2-3 secs suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time. Blood pressure Narrow pulse pressure:less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes - aortic stenosis, congestive heart failure and cardiac tamponade. Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes - aortic regurgitation and aortic dissection. Difference between arms: > 20mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.What is the definition of a postural hypotension ?Fall in systolic blood pressure of at le t (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.Postural Hypotension (Orthostatic Hypotension) - Condition where blood pressure drops abnormally when they stand up after sitting or lying down. - Not everyone will have symptoms - Can lead to dizziness/ light-headedness/fainting & possible falls. - More common in elderly/ PD or diabetes (affect the part of the nervous system that helps to control blood pressure). - Dehydration - Medications (for example, to treat high blood pressure (diuretics or alpha blockers e.g. tamsulosin). If symptoms of cerebral hypoperfusion à syncope and fallsManagement Drinking more water Compression stockings Raising the head of the bed Learning body movements to counteract the drop in blood pressure Off label medication – fludrocortisoneHead and Neck Eyes ?Sunken in appearance Mucous Membranes ? Dry JVP (is it raised? – usually raised in overload and unable to observe in dehydration) Carotid Pulse – volume and characterChest Respiratory rate Auscultate heart sounds Abnormal heart sounds in hypervolaemia - A gallop rhythm(i.e. a third heart sound occurring after the normal ‘lub’ ‘dub’ heart sounds) may be seen in hypervolaemia (elevated atrial and ventricular filling pressures) - Typically associated with heart failurealthough can be present in healthy patients Auscultate lungs Coarse crackles à pulmonary oedema. Absent air entry & stony dullness on percussion à pleural effusion.Abdomen Legs DON’T FORGET ABOUT SACRAL OEDEMAHow to assess for shifting dullness 1. Percuss from umbilical region to the patient’s left flank. If dullness is noted, this may suggest the presence of ascitic fluid in flank. 2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability). 3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area. 4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).What would you do if you were asked to prescribe fluids for patient that was hypovolaemicThings to consider .. What was there NEWS Score – ?low BP Tachycardic ?Are they in shock Resuscitation – STAT 250mls if CCF/500mls bolus – STAT or 999 rate Maintainence fluids – average 70kg needs approx. 2-2.5L /dayFurther Investigations Serial Weights FBC U&E abdominal ultrasound to rule out ascites.hocardiogram to assess cardiac function or an Accurate fluid balance: including daily weights, urine output, fluid intake and stool chart, catheterise. Urine and serum osmolality Posture test/Tilt table testA 69-year-old man is started on tamsulosin for benign prostatic hyperplasia. Which one of the following best describes the side-effects he may experience? A Urgency + insomnia B Dizziness + postural hypotension C Urinary retention + nausea D Urgency + erectile dysfunction E Erectile dysfunction + reduced libidoThank you! Please complete feedback..