The utility of routine physical examination in the ICU

 Question 12 from the first paper of 2003 asked whether or not there is any merit to the routine practice of examining ICU patients. Specifically, it was a "critically evaluate" question.

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)
• Some important functional assessments cannot be carried out reliably using any other convenient method. For instance, physical examination is always going to be the gold standard where it comes to assessing higher cognitive function and subtle neurological dysfunction, particularly of the cranial nerves.
• Physical examination of the neurological system in particular takes a patient-centered approach, as it tests the functions of the neurological systems being tested. Structural imaging of these systems is less important in terms of outcome.

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 supersedes the examination of the JVP)

Disadvantages:

• Poor sensitivity and specificity
• New pathology may be missed
• Interpreter-dependent
• Poor reproducibility 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% included non-classical components (such as assessment of arterial and ventilator waveforms). Everybody was in agreement that percussion was the least useful physical sign.
• A similar study (Vasquez et al, 2015)  surveyed critical care staff and found that half of them considered physical examination to be of limited utility in the intensive care unit. Most extended the definition of physical examination to include data derived from monitoring (97%), life support equipment (99%) and bedside imaging devices (92%). Of the answers given to a set of clinical scenarios, only 15% were reasoned using findings of clinical examination.
• Time spent at the bedside during ICU rounds was about 11% in one audit - most ICU doctors spend their time away from the patient's bed,  in hallways or conference rooms (Miller et al, 1992)