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The Rational Clinical Examination
March 17, 1999

Is This Patient Hypovolemic?

Author Affiliations

Author Affiliations: Department of Medicine, University of Washington, Seattle-Puget Sound VA Health Care System, Seattle (Dr McGee); Department of Cardiovascular Medicine, Massachusetts General Hospital, Boston (Dr Abernethy); and Department of Medicine, Ambulatory Care, Duke University and Durham Veterans Affairs Medical Center, Durham, NC (Dr Simel).


The Rational Clinical Examination Section Editors:David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.

JAMA. 1999;281(11):1022-1029. doi:10.1001/jama.281.11.1022

Objective To review, systematically, the physical diagnosis of hypovolemia in adults.

Methods We searched MEDLINE (January 1966-November 1997), personal files, and bibliographies of textbooks on physical diagnosis and identified 10 studies investigating postural vital signs or the capillary refill time of healthy volunteers, some of whom underwent phlebotomy of up to 1150 mL of blood, and 4 studies of patients presenting to emergency departments with suspected hypovolemia, usually due to vomiting, diarrhea, or decreased oral intake.

Results When clinicians evaluate adults with suspected blood loss, the most helpful physical findings are either severe postural dizziness (preventing measurement of upright vital signs) or a postural pulse increment of 30 beats/min or more. The presence of either finding has a sensitivity for moderate blood loss of only 22% (95% confidence interval [CI], 6%-48%) but a much greater sensitivity for large blood loss of 97% (95% CI, 91%-100%); the corresponding specificity is 98% (95% CI, 97%-99%). Supine hypotension and tachycardia are frequently absent, even after up to 1150 mL of blood loss (sensitivity, 33%; 95% CI, 21%-47%, for supine hypotension). The finding of mild postural dizziness has no proven value. In patients with vomiting, diarrhea, or decreased oral intake, the presence of a dry axilla supports the diagnosis of hypovolemia (positive likelihood ratio, 2.8; 95% CI, 1.4-5.4), and moist mucous membranes and a tongue without furrows argue against it (negative likelihood ratio, 0.3; 95% CI, 0.1-0.6 for both findings). In adults, the capillary refill time and poor skin turgor have no proven diagnostic value.

Conclusions A large postural pulse change (≥30 beats/min) or severe postural dizziness is required to clinically diagnose hypovolemia due to blood loss, although these findings are often absent after moderate amounts of blood loss. In patients with vomiting, diarrhea, or decreased oral intake, few findings have proven utility, and clinicians should measure serum electrolytes, serum blood urea nitrogen, and creatinine levels when diagnostic certainty is required.

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