Clinical Examination Skills in the Adult Critically Ill Patient

262 Pages·2018·21.389 MB·English

by  Martin W. Dünser, Daniel Dankl, Sirak Petros, Mervyn Mer

Clinical Examination
Skills in the Adult
Critically Ill Patient
Martin W. Dünser
Daniel Dankl
Sirak Petros
Mervyn Mer
Editors
123
Clinical Examination Skills in the
Adult Critically Ill Patient
Martin W. Dünser • Daniel Dankl
Sirak Petros • Mervyn Mer
Editors
Clinical Examination
Skills in the Adult
Critically Ill Patient
Editors
Martin W. Dünser Daniel Dankl
Department of Anesthesiology and Department of Anesthesiology,
Intensive Care Medicine Perioperative Medicine and General
Kepler University Hospital Intensive Care
Linz Salzburg University Hospital and
Austria Paracelsus Private Medical University
Salzburg
Sirak Petros Salzburg
Medical Intensive Care Unit and Centre Austria
of Haemostaseology
University Hospital Leipzig Mervyn Mer
Leipzig Divisions of Critical Care and
Germany Pulmonology, Department of Medicine,
Charlotte
Maxeke Johannesburg Academic
Hospital and Faculty of Health Sciences
University of the Witwatersrand
Johannesburg
South Africa
ISBN 978-3-319-77364-3 ISBN 978-3-319-77365-0 (eBook)
https://doi.org/10.1007/978-3-319-77365-0
Library of Congress Control Number: 2018944269
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To Walter Hasibeder and Jukka Takala who taught me the art of
caring for the critically ill patient, and to my beloved wife Evi
who taught me everything else.
Martin W. Dünser
*
To Martin.
Daniel Dankl
*
To my patients, who keep teaching me and warn me not to take
anything for granted.
Sirak Petros
*
May this book serve as a source of inspiration for all in this
privileged profession and field who are passionate about
people, patients, and the practice of pristine clinical
medicine – for the betterment of all!
Gracious thanks to all the wonderful teachers, master
clinicians, and icons who stimulated my own passion for
clinical medicine.
Special thanks to all the fabulous contributors, and co-editors
for their enormous contributions. A particular special thank
you to Martin Dünser for his unstinting support, enthusiasm,
outstanding contributions, humility, and brilliant insights and
personal skills.
Thanks to my beautiful family for their understanding and
support during the many hours (enjoyable!) working on the book.
Mervyn Mer
Foreword
I was brought up reciting the holy trinity of “History, examination, investiga-
tions.” A careful history and thorough examination will often yield the
answer, or narrow it down to a small differential diagnosis. Subsequent inves-
tigations would then simply corroborate the strong clinical suspicion.
Unfortunately, modern medicine has devalued an appreciation of the role of
the clinical exam. Junior doctors increasingly focus on computer screens to
chase up a battery of blood tests, CT scans, and the like at the expense of a
bedside presence and to the patient’s detriment. A daily examination will not
infrequently pick up the clinical sign that wasn’t present (or was missed) on
admission—and this revelation may impact heavily upon management and
outcome. A sedated or agitated patient often poses additional challenges. The
publication of this excellent book focusing on clinical examination of the
critically ill patient is thus both timely and much needed. Succinct, clear
guides and prompts direct the practitioner to consider diagnosis in the light of
clinical features. Back to the future!
London, UK Mervyn Singer
2018
vii
Preface
Over the last few decades, technical advances brought countless improve-
ments to emergency and intensive care. Single clinical examination tech-
niques to assess the critically ill patient have been replaced by more sensitive
laboratory or imaging technologies. With the widespread availability of these
diagnostics, the use of the physical examination has declined and all too often
become underappreciated. Diagnostic clinical skills are frequently underused
in clinical practice and thus became oblivious to many intensivists. Despite
all technical and diagnostic advances, the physical examination of the criti-
cally ill patient remains of crucial importance. Although single examination
steps may be inferior when compared to laboratory or radiological tech-
niques, the clinical examination is of unique value to integrate and understand
the patient’s history, general impression, and numerous clinical details. It
remains the fundament of care which guides the clinician in the overall and
organ-specific management of the critically ill patient. In addition, the physi-
cal examination is of enormous value to indicate and determine the pre- and
post-test probabilities of diagnostic methods.
The contemporary literature largely focuses on the physical examination
of the stable and ambulatory patient. These examination techniques are com-
monly not applicable to the critically ill and foster reliance on laboratory and
imaging technologies in these patients. With this illustrated book, we intend
to close this gap and reintroduce physical examination steps which can be
meaningfully applied also in unstable and critically ill patients wherever they
are cared for: in the pre-hospital setting, the emergency room, the intensive
care unit, or on the hospital ward.
Linz, Austria Martin W. Dünser
Salzburg, Austria Daniel Dankl
Leipzig, Germany Sirak Petros
Johannesburg, South Africa Mervyn Mer
2018
ix
Contents
Part I General Approach to the Critically III Patient
1 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Martin W. Dünser, Daniel Dankl, Sirak Petros,
and Mervyn Mer
2 The First Impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Martin W. Dünser, Daniel Dankl, Sirak Petros,
and Mervyn Mer
3 Checking Vital Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Martin W. Dünser, Daniel Dankl, Sirak Petros,
and Mervyn Mer
4 Recognizing Preterminal Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Martin W. Dünser, Daniel Dankl, Sirak Petros,
and Mervyn Mer
Part II E xamining Single Organ Systems
5 The Airway and Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Martin W. Dünser, Daniel Dankl, Sirak Petros,
and Mervyn Mer
6 The Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Martin W. Dünser, Daniel Dankl, Sirak Petros,
and Mervyn Mer
7 The Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Martin W. Dünser, Ronny Beer, Sirak Petros, and Mervyn Mer
8 The Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Martin W. Dünser, Daniel Dankl, Sirak Petros,
Wilhelm Grander, Dietmar Öfner-Velano, and Mervyn Mer
9 The Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Martin W. Dünser, Sirak Petros, Wilhelm Grander,
Dietmar Öfner-Velano, and Mervyn Mer
xi
xii Contents
10 The Hydration Status and the Kidneys . . . . . . . . . . . . . . . . . . . . . 137
Martin W. Dünser, Wilfred Druml, Sirak Petros,
and Wilhelm Grander
11 The Neuromuscular System and Spinal Cord . . . . . . . . . . . . . . . 143
Martin W. Dünser and Ronny Beer
12 The Coagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Martin W. Dünser, Sirak Petros, and Herbert Schöchl
Part III Systematic Examination Schemes
13 The Patient in Respiratory Distress . . . . . . . . . . . . . . . . . . . . . . . 165
Martin W. Dünser and Daniel Dankl
14 The Patient in Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Martin W. Dünser and Daniel Dankl
15 The Patient with Neurological Disease . . . . . . . . . . . . . . . . . . . . . 177
Martin W. Dünser and Daniel Dankl
16 The Patient with Severe Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Martin W. Dünser and Daniel Dankl
17 The Patient with Suspected Infection . . . . . . . . . . . . . . . . . . . . . . 201
Martin W. Dünser and Daniel Dankl
18 The Patient in Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Martin W. Dünser and Daniel Dankl
19 The Intoxicated Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Martin W. Dünser and Daniel Dankl
20 During the ICU Ward Round . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Martin W. Dünser and Daniel Dankl
Part IV Appendix
21 Dermatologic Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Josef Koller and Martin W. Dünser
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Contributors
Ronny Beer Neurological Intensive Care Unit, Department of Neurology,
Innsbruck Medical University, Innsbruck, Austria
Daniel Dankl Department of Anesthesiology, Perioperative Medicine and
General Intensive Care, Salzburg University Hospital and Paracelsus Private
Medical University, Salzburg, Austria
Wilfred Druml Medical University of Vienna, Vienna, Austria
Martin  W.  Dünser Department of Anesthesiology and Intensive Care
Medicine, Kepler University Hospital, Johannes Kepler University Linz,
Linz, Austria
Wilhelm Grander Department of Internal Medicine, Academic Teaching
Hospital Hall in Tirol, Hall in Tirol, Austria
Josef Koller Department of Dermatology, Salzburg University Hospital and
Paracelsus Private Medical University, Salzburg, Austria
Mervyn Mer Divisions of Critical Care and Pulmonology, Department of
Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty
of Health Sciences University of the Witwatersrand, Johannesburg, South
Africa
Dietmar Öfner-Velano Department of Visceral, Transplant and Thoracic
Surgery, Centre of Operative Medicine, Innsbruck Medical University,
Innsbruck, Austria
Sirak Petros Medical Intensive Care Unit and Centre of Haemostaseology,
University Hospital Leipzig, Leipzig, Germany
Herbert  Schöchl Department of Anesthesiology and Intensive Care
Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of
the Paracelsus Private Medical University, Salzburg, Austria
xiii