Head to Toe, Front & Back, Physical Examination

Physical examination in the critically ill extends well beyond the patient. It includes the interface of patient and technology - the lines the monitors, the drains, even the type of bed the patient is on. You must start accumulating information the second you go into the patient's room or approach the bed. A good intensivist can walk into the room of any patient in ICU without any knowledge of the patient, and within 2 minutes know virtually everything about the patient without consulting the notes.

Walking up to the bed:
Has the patient been placed on isolation precautions (MRSA / Vancymycin resistant enterococcus (if so make sure you check how the diagnosis was made and if isolation is, in fact, appropriate)? What kind of monitors or machines are in the room – a continuous cardiac output monitor/esophageal doppler, a dialysis machine (check the numbers and the content of the dialysis fluid before you leave), an intra-aortic balloon pump, an ECMO machine, a mechanical ventilator or high frequency oscillator, an spinal halo or intracranial pressure monitoring device? Is there an unusual odour in the room that would suggest pseudomonas of C.Difficile infection?

End of bed
Is the patient moving about, agitated, fighting the ventilator, or comatose. Is the patient pale, jaundiced, cyanosed or diaphoretic? Does the patient have an extensive skin rash. Is the patient lying flat in the bed (more likely to aspirate), sitting up (better respiratory mechanics) or prone (lung recruitment). What kind of bed is the patient in - a standard bed, a percussion bed, a rotating bed, a Rotarest or proning bed (this will tell you a lot about the patient - what is wrong with them, how long they have been in ICU)?

Eyeball the monitors to ensure that the patient is not in physiologic distress – hypotensive, hypertensive, desaturating, tachy- or bradycardic or arrhythmic. Look at the pressure waveforms - are they damped? Do the numbers on display accurately reflect the physical condition of the patient (measurement error is frighteningly common in intensive care)?
 

Examining the patient
Check a mental state by talking to the patient – determine level of consciousness using AVPU (awake, responding to verbal stimuli (ideal), responding to painful stimuli, unresponsive). Explain, even if the patient is unresponsive, who you are and that you are going to examine them.

Examine the patient’s head: are the eyes open? Are they too edematous to close (and thus risk corneal ulceration)? Are the pupils equal and reacting to light? Does the patient have a naso- or oro-gastric tube? Does the patient have a feeding tube? Is the patient intubated – oral, nasal or tracheal? Have a quick look at the mouth to ensure that the endotracheal tube is not causing pressure injury.

Examine the neck: does the patient have a tracheostomy or a cervical collar (is it an appropriate fit?). Feel for crepitus in the supraclavicular area (associated with pneumothorax, important if the patient was involved with trauma or is mechanically ventilated), are the jugular veins distended suggesting fluid overload. Does the patient have a neck or subclavian central line? If so, is it secured? Is the site infected?

Examine the chest: Is there an old sternotomy or thoracotomy scar? Is there any chest drain (if so examine the site, the drainage bottle – how much? Bloodstained? Is there an air leak present?).  Does the chest expand evenly? Does the patient have a parasternal heave or a thrusting cardiac apex? Listen to the heart sounds; are there any murmurs or evidence of a pericardial friction rub (uremia/cardiac surgery)? Listen to the lung fields in the apices and axillae, looking for air entry, crackles and bronchial breathing. Sit the patient forward and listen to the lower zones of the lungs. Look for decubiti at the back of the head and for sacral edema in this position.

Examine the arms: are they equal in size – is there unilateral edema (suggestive of axillary vein thrombosis)? Does the patient have an arterial line? Examine the site – any inflammation or pus? Carefully look at the fingers of that hand (any blanching or ischemic changes). Then examine the fingers of the other hand.

Examine the abdomen: is it distended, is there a wound, drains or dressings. If so, take down the dressings and examine the wound and drain sites – are the sites red and inflamed, or dry and healing? Is there any pus? If there are drains, look at the drainage bottles – what do they contain – blood, serous fluid? How much? Palpate the abdomen feeling for masses and hepato-splenomegaly. Percuss the abdomen to confirm organ enlargement, bladder distension, or the presence of ascites (shifting dullness) or bowel air (tympanic).

Examine the groin area: are there any femoral lines (including arterial sheaths and intra-aortic balloon pumps)? Is there any material oozing along the urinary catheter from the ureteral meatus or evidence of gential or flexure candidal infection. How much is in the urinary catheter bag, and what color is it (light or dark yellow – dehydration – or red (myoglobin).

Examine the legs: are they equal in size. Does the patient have compression stockings or sequential compression devices (SCDs - are they switched on?) for DVT prophylaxis? Is there any evidence of deep venous thrombosis or thrombophlebitis? Is there any ankle edema? Are there any lines in the feet? Are there any mottled or ischemic toes?

Roll the patient on his/her side and examine the posterior aspect of the body. Are there any pressure sores? Is there any evidence of skin or deep tissue infection? Has a rectal tube been placed?

Look at the monitor
What is the heart rate? Is it regular? What is the blood pressure? Does the arterial line correlate with the blood pressure cuff? Is the heart rate appropriate for the blood pressure (click here)? What is the central venous pressure (CVP)? Is there a good trace? Is there a PA catheter present? What is the PAP and the cardiac output? If you are unhappy with any of the readings or traces, turn the transducer off to the patient and open to the air and check that the monitor is zeroed? Then flush the line and check the reading again.

If the patient is ventilated, have a look at the ventilator: what settings is the patient on? Is the patient breathing spontaneously? Look at the waveforms (click here) - is there any evidence of dysynchrony or gas trapping?

Before leaving the bedside, look at all of the infusion pumps – what is running and at what rate?

Copyright Patrick Neligan 2001-2002

Please note: these tutorials are for personal study purposes only.  They are not currently peer reviewed, and no responsibility will be taken for mistakes or inaccuracies. Reproduction of information is forbidden. All material is copyrighted by the GasWorks Group.