Question 12

College Answer

Few studies have addressed the potential benefits of clinical examination in the critically ill.  Those that have addressed estimation of filling pressures have been disappointing.  In general benefits of clinical examination are only supported by lower levels of evidence (including extrapolation from other patient populations).

In the critically ill, as history may be difficult to obtain, especially in an emergency, clinical signs alone are used to guide treatment and investigation until more definitive information is available. Candidates should discuss potential risks & benefits (eg. early detection guiding treatment vs lack of sensitivity [missing disease states] and sensitivity [wrongly excluding differential diagnoses].

Types of information that are available and may influence management (either in an emergency or otherwise) include: assessment of airway and breathing (eg. position of ETT cuff, chest movement, breath sounds), circulation (eg. presence of pulses: peripheral/central and estimate of peripheral perfusion); neurological assessment (AVPU/GCS/pupils, localising signs, tone & reflexes, sensation);  presence  of  skin  lesions  (rash:  purpura,  erythematous,  papular;  spider  naevi  etc); localised tenderness (eg. limb, abdominal quadrant etc); presence of abnormal masses (eg. lymph nodes,  hepatosplenomegaly);  fundoscopic  assessment  (eg.  subhyaloid  haemorrhages, papilloedema); assessment of invasive devices/dressings/drains etc.

Discussion

Rationale:

• History and physical examination is the mainstay of diagnosis in non-ICU environments
• ICU patients are frequently unable to offer a history
• Physical examination may be able to reveal new pathology, which would otherwise have not been suspected from routine bloods and radiography.
• Clinical features are more reliable than other methods in the diagnosis of certain conditions (eg. delirium, weakness, etc)

Advantages:

• Cheap
• Non-invasive (mostly)
• Sequential
• May detect deterioration early
• Better than imaging for neurological assessment
• Assesses function as well as structure
• Many ICU devices enhance physical examination technique (eg. CVP waveform supercedes the examination of the JVP)

Disadvantages:

• Poor sensitivity and specificity
• New pathology may be missed
• Interpreter-dependent
• Poor reproduceability of findings
• Many barriers to traditional techniques in the ICU (eg. the patient is uncooperative, dressings and lines obscure physical signs)

Evidence:

• Little evidence in support of this widespread practice
• Benefits of clinical examination are extrapolated from outpatient population.
• A survey of ICU physicians from California has revealed that 59% think physical examination has limited utility, and 94% uncluded non-classical components (such as assessment of arterial and ventilator waveforms). Everybody was in agreement that percussion was the least useful physical sign.

Rudiger, A. "[The clinical examination of the critically ill patient in the intensive care unit]." Therapeutische Umschau. Revue therapeutique 63.7 (2006): 479-484.

Sackett, David L. "A primer on the precision and accuracy of the clinical examination." Jama 267.19 (1992): 2638-2644.

Dobb, G. J., and L. J. Coombs. "Clinical examination of patients in the intensive care unit." British journal of hospital medicine 38.2 (1987): 102-4.

Hillman, K., G. Bishop, and A. Flabouris. "Patient examination in the intensive care unit." Intensive Care Medicine. Springer New York, 2002. 942-950.

Guillamet, R. Vazquez, et al. "Physicians Perceptions Of The Utility Of Physical Exam In The Intensive Care Unit. A Qualitative Study." Am J Respir Crit Care Med 185 (2012): A1661.