I hear clinicians say the physical exam is dead.☠️ This is just not true
Here are the 10 most important clinical exam findings in the ICU
A 🧵
(and some things you can probably stop doing…)
#medtwitter #foamed
1/10) Capillary Refill Time
This is the best and most easily available microcirculatory surrogate for perfusion.
We can’t tell what the renal, gut, brain, and liver perfusion is doing by looking at the patient – but by simply examining the cap refill time we can get a pretty good estimate.
Normal: 2 seconds or less
I check fingers: press lightly for 10 seconds until blanching then release. Use a glass slide if available.
2/10) Vitals
Specifically:
Pulse pressure = SBP minus DBP. If low (<30mmHg or 40mmHg) indicator of potential low SV
RR – most useful vital for respiratory patients (and weaning)
HR – critical to diagnose etiology of shock (tachy –> ? compensatory. Brady –> ? cause)
3/10) Accessory Muscle Use
Your decision to intubate a patient depends on a few things:
1) Oxygenation
2) Ventilation
3) Work of breathing
4) Cough/Secretion Clearance
A patient with hypoxia without accessory muscle use can have a few different things going on:
1) Normal lung compliance –> consider shunt as a cause of hypoxia.
2) Neuromuscular weakness –> these patients might not be able to mount a strong accessory muscle use
3) Not that sick/distressed
If I see a very hypoxic person without accessory muscle use I often think of shunt and will consider
1) pulmonary shunt vs.
2) intracardiac shunt (bubble study)
4/10) Peripheral edema
Understanding whether someone has interstitial edema is crucial. Not only can this limit mobility, but I view it as a surrogate of edema for other organs/tissue beds.
Note: peripheral edema is not volume status. In fact, volume status is a somewhat arbitrary concept.
Volume status = some combination of…
1) Cardiac output / forward flow
2) Left sided congestion
3) Right sided congestion
4) Mean systemic filling pressure
5) Peripheral edema
6) Tissue perfusion
7) Whether the clinician wants to give fluids vs. lasix
You can’t get the diagnosis of interstitial / peripheral edema from invasive measurements or echo. Only good old fashioned exam.
5/10) Mottling
Mottling is an ominous sign and correlated with mortality.
It is a marker of tissue hypoperfusion.
Mottling = figure out cause ASAP.
6/10) Skin temperature
Skin temperature gives you a sense of systemic vascular resistance (SVR)
Warm = low/normal SVR
Cold = high SVR
This can help phenotype shock, but more importantly, guide decisions on whether vasopressors will be of additional benefit.
Hypotensive + warm = greater likely vasopressors will restore hemodynamics.
7/10) Abdominal Exam (tenderness + distension)
Examining the abdomen can tell you so much about a patient.
Distended?
Tender?
Peritonitis?
When you hear a patient is having feed intolerance, one of the first things you should do in the ICU is examine their belly!
Also, badness hides in the belly. Undifferentiated badness in the ICU = examine belly +- imaging.
8/10) Neuro exam (CN + motor)
The neuro exam in the ICU (especially the coma exam) is crucial.
If you want to learn all the coma exam PEARLS then follow @caseyalbin . She is the neuroICU guru I look up to.
#neurotwitter #neurology
9/10) Assessing for cough strength
This is too often overlooked.
When someone is in respiratory distress (or even just someone who has been extubated), their ability to clear secretions is essential for staying extubated.
The more secretions you have, the stronger the cough you need to clear them.
I ask patients to take deep breaths and cough to demonstrate this for me. When really weak, if they have secretions, will consider cough assist and more aggressive chest physio.
10/10) Things that are not routinely part of my exam.
JVP – difficult to assess and a static marker of right atrial pressure which does not inform whether to give fluids. It is not an oil dip stick.
Bowel sounds – simply stop.
Carefully palpating for splenomegaly or liver – if you care enough to examine in detail (e.g. it would actually change your ddx) then do a POCUS or other imaging modality to quickly and way more accurately diagnose.
Heart Auscultation – rarely does this change management. If you have a patient that you are considering a valvulopathy (and it is potentially meaninfully impacting management), you should just do a critical care echo or formal echo.
Lung Auscultation – this can be useful to listen for wheezes, but if you have a high enough pre-test probability for pulmonary pathology that you are basing decisions on something you hear, you should get a CXR +- lung ultrasound
deemagclinic
deemag and chest clinic 