Critically evaluate the role of clinical examination in the management of the critically ill patient.
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.
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