If dehydration is suspected, physical examination begins with a check of postural signs for a drop in blood pressure and rise in pulse. The skin is examined for signs of thyroid disease, the neck for evidence of thyroidectomy, the lower extremities for diminished or absent pulses, muscle wasting, and fasciculations, and the nervous system for focal weakness and absent or abnormal deep tendon reflexes. If tetany is a consideration, one can try to elicit the facial spasm of Trousseau’s sign by tapping the facial nerve or the carpal spasm of Chvostek’s sign by inflating the arm cuff above systolic pressure.
Laboratory determinations can be very limited. For the majority of people who present with a clinical story of nocturnal muscle cramps, laboratory testing is unlikely to provide additional information. Other situations do require a few simple tests. If the patient with ordinary cramps is diabetic and taking insulin, then testing for hypoglycemia is indicated. If severe dehydration and hyponatremia are suspected, then determinations of serum sodium, blood urea nitrogen (BUN), and creatinine can guide assessment and treatment. The patient with possible tetany needs a check of sodium, potassium, calcium, albumin (to interpret the calcium level), and magnesium. Consideration of thyroid disease is best pursued by obtaining a serum thyrotropin (TSH) determination. The patient with fasciculations and possible lower motor neuron disease may need a nerve conduction study.
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