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Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | Clinical Examination of the Critically Ill

Clinical Examination of the Critically Ill

by Chris Nickson, Last updated September 1, 2015

Reviewed and revised 1 September 2015

OVERVIEW

  • Pros and cons of clinical examination of the critically ill

ARGUMENTS FOR

  • history is often difficult to obtain in the critically ill, clinical signs alone are used to guide treatment and investigation until more definitive information available
  • quick and easy to perform
  • types of information influence management (especially in an emergency):
    • airway: not patent or protected -> intubate, ETT position
    • breathing: chest movement, breath sounds (e.g. wheeze)
    • circulation: presence of pulses, peripheral and central cyanosis, estimation of peripheral perfusion
    • neurological: AVPU, GCS, pupils, localising signs, tone and reflexes, sensation
    • skin: lesions, rash, purpura, erythema, papular, spider naevi
    • localised tenderness: limb, abdominal quadrant
    • abnormal masses: lymph nodes, hepatosplenomegaly
    • fundoscopy: subhyaloid haemorrhages, papilloedema
    • assessment of invasive devices, dressings, drains…
  • important information for neuro-prognostication (e.g. post-cardiac arrest, severe TBI)

ARGUMENTS AGAINST

  • lack of sensitivity (missing disease states)
  • lack of specificity (wrongly excluding differential diagnoses)
  • few high quality studies address the benefits of clinical examination in the critically ill
  • general benefits of clinical examination are only supported by lower levels of evidence (including extrapolation from other patient populations)

References and Links

Lifeinthefastlane.com

  • Clinical Examination Video Database

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About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

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