Fluid status in five looks
Fluid status in five looks
You freeze at the end of the bed because you say "euvolaemic" after glancing at the ankles. A registrar does not want a guess. They want five looks in the same order, then one sentence: dry, wet, or you cannot tell yet.
This is not a clerking. It is not a 90-second present. It is how you decide whether this person needs fluid, needs it holding, or needs a senior before anyone charts another bag.
Confirm the patient, the last weight if there is one, and what is currently running. Treat the patient, not the last bag on the chart.
What students actually say
"He looks a bit dry. Ankles are fine. Maybe a bag of normal saline?"
That sentence has no mucous membranes, no JVP, no chest, no input/output, and no U&E. It is a vibe with extra words.
If you cannot name two findings that agree, you have not assessed fluid. You have guessed.
Look 1: the person from the end of the bed
Do this before you touch anyone.
Work of breathing, colour, whether they can finish a sentence.
Confused, drowsy, or new restlessness. That can be low perfusion, not "they're tired."
The drip stand: what is running, how fast, since when. A bag you did not notice is still a bag they are getting.
If they look shocked or drowning, say that out loud and get a senior. Do not finish the five looks while they are peri-arrest.
Look 2: dry on the face, or not
Mouth, tongue, axillae if that is how you were taught, skin turgor only as a supporting sign in the right patient.
Dry mucous membranes plus thirst plus a rising urea is a story.
A dry mouth after oxygen and nil by mouth is not the whole diagnosis. Name the confounder.
Capillary refill and whether the hands are cool. One sign is not a volume state.
Do not call someone dry because they asked for water.
Look 3: the neck, then the chest
JVP if you can see it. If you cannot, say you cannot. Inventing a JVP is worse than no JVP.
Raised JVP, wet bases, breathless lying flat: wet until a senior says otherwise.
Flat JVP, clear chest, postural dizziness: dry until the bloods argue.
Crackles that do not move, or a known fibrosis, are not "overload" on their own.
Sit them up before you decide the chest is wet. A slumped patient sounds wet.
Look 4: where the water actually is
Sacrum, not just the ankles they put on show. Ankles can be empty while the sacrum is soaked.
Pitting oedema, how far it goes, whether it is new.
Today's weight versus yesterday if the chart has it. A kilogram overnight is a finding. No weight written is also a finding.
Ascites, a tight abdomen, or a huge pleural effusion can make the legs lie.
Oedema is not always too much fluid in the tank. Hypoalbuminaemia and dependent oedema exist. If the JVP is flat and they are dizzy, do not diurese the ankles.
Look 5: the chart and the U&E, last, on purpose
You look at the numbers after the person, so the printout does not become the exam.
Input and output for the last 24 hours, and whether anyone actually measured it.
Urea, creatinine, sodium, and the last potassium. A climbing urea with a falling urine output is not "a bit dry."
What went in: saline, Hartmann's, blood, oral intake. What came out: urine, drain, stool, insensible if they are febrile.
If input/output is blank, that is the finding. Do not invent a balance.
The one sentence you owe
After five looks, say one of these. Not a paragraph.
"Dry: dry mouth, flat JVP, urea up, oliguric. I would hold the diuretic and ask about fluid. I have not charted a bag."
"Wet: raised JVP, sacral oedema, crackles, plus 1.4 kg overnight. I would sit them up and hold the next bag."
"Cannot tell yet: oedema in the legs, flat JVP, no weight, no fluid chart. I need a senior before anyone writes a bag or a diuretic."
"Euvolaemic" is allowed only if two looks agree and nothing urgent is moving. If you say it after Look 1, you guessed.
Three examples
1. The ankles that talked you out of looking
Ankles thin. Sacrum soaked. Breathless at 30 degrees. JVP up. Still due 1 litre saline from overnight.
Impression: wet. The ankles lied.
Next action: hold the bag, sit them up, senior. Do not finish the prescribed litre because "it's already written."
2. The dry mouth after a scan
Nil by mouth since midnight. Dry tongue. Blood pressure 98/60 after ramipril. Urea 12, was 7. Urine output not written.
Impression: likely dry, and you do not have a balance.
Next action: lying and standing if they can, hold the next ACE inhibitor pending senior, do not guess a rate. Confirm locally. Never invent findings.
3. The oedema you were about to diurese
Legs to the knees. JVP not seen. Cool hands. Sodium 128. Albumin 22. Patient dizzy on standing.
Impression: not straightforward overload. The tank may be empty even if the legs are full.
Next action: senior before any diuretic. Do not chart furosemide because the socks left a dent.
The three ways "euvolaemic" becomes a lie
You looked at the ankles and skipped the sacrum, the JVP, or the bag still running.
You read the U&E first and fitted the exam to the urea.
You charted a bag or a diuretic because it felt decisive, before two looks agreed.
If any of those happened, repeat the five looks. Do not add a sixth speech.
How to practise this until it is automatic
Before the round, take one patient. Five looks, sixty seconds, one sentence. If you over-run, you started narrating.
After the registrar asks "wet or dry?", that is the sentence. If you stall, you did not look.
Write which look you skipped last time. That is the one you do first tomorrow.
Confirm locally. Never invent findings. Do not chart fluids or diuretics you are not allowed to chart.
The Ward Workbook is the daily sheets for this: before clinic, one-patient sheet, after clinic, and the jobs you actually finish. It is $9 on its own, or in the complete set ($33) with How to Study Medicine, How to Read Imaging, and How to Read Labs. Pay once. Study Kit is included free with every purchase.
It does not replace your lectures, your hospital, or a question bank.