General Appearance

• Reposition
  As able to maximise exposure and assess-ability.
• Maximise exposure
  Folding blankets down and in to the midline allows rapid and near-complete exposure whilst still preserving some modesty.

Findings on General Inspection

Component	Inspection
General	Position Obesity Cachexia Wounds Drains Dressings Burns Lines Access Position Signs of recovery include: Sleeping in the lateral position Lying with crossed legs
Respiratory	Respiratory pattern Cheyne-Stokes respiration Biot breathing Apneustic respiration Paradoxical breathing Positional dyspnoea Trepopnoea Work of breathing Steroid purpura Cushingoid appearance Tracheal aspirates
Cardiovascular	Positional dyspnoea Orthopnoea Platypnoea Xanthoma Marfanoid habitus Centralisation Peripheral perfusion Livedo reticularis Oedema
Neurological	Speech patterns Slurred Hoarse Dysarthria Poor enunciation with intact fluency, comprehension, and repetition. Aphasias
Endocrine and Metabolic
Renal and Fluid	Volume state
Gastrointestinal	Jaundice Foetor hepaticus
Haematological
Integumentary	Muscle bulk Wasting Malnutrition Cachexia Purpura Rashes Petechiae Purpura Erythema gangrenosum Drug exanthem TENS Erythema multiforme Candidiasis
Trauma
Infective
Malignant
Toxic
Immune	Vasculitic rashes
Congenital
Obstetric	Oedema Bruising/ecchymoses

Features

Respiratory

• Cheyne-Stokes respiration
  • Alternating episodes hyperpnoea followed by apnoeic spells
    • Apnoea may last up to 45s, but is usualy 5-10s
  • Generally indicative of acute cerebral or chronic cardiac pathology
  • Physiologic in infants and at high altitude

Cheyne-Stokes Respiration

• Biot breathing
  Similar to Cheyne-Stokes, but abrupt alteration between apnoea and hyperpnoea and less regular intervals.
  • Indicative of pontine or brainstem injury

Abdominal motion indirectly indicates the function of the diaphragm.

• Apneustic breathing
  Irregular respiration rate and tidal volume, classically with an end-inspiratory hold prior to commencing the next breath.
  
  
• Paradoxical breathing
  Inward movement of the chest while the abdomen raises during inspiration, which occurs in:
  • Upper airway obstruction
  • Severe respiratory distress
  • Diaphragmatic dysfunction
    
    
• Obstructive breathing
  Expiratory airflow limitation may lead to:
  • Active abdominal contraction during expiration
  • Slow and incomplete descent of the chest
  • Pursed-lip expiration
    Generation of PEEP, maintaining opening of small airways.
  • E-time > I-time
    
    
• Restrictive breathing
  Prolonged, forceful inspiration due to inspiratory airflow limitation.

Obstructive and restrictive breathing can occur in the same patient.

• Trepopnoea
  Dyspnoea occurring in one lateral position but not the other, signifying worse disease in the non-dependent lung which occurs due to poorer V/Q matching when the diseased lung is in the dependent position.

Cardiovascular

• Orthopnoea
  Dyspnoea relieved in the sitting or standing position, due to a ↓ in VR and pulmonary venous congestion.

Inability to lie flat is a significant marker of severe RV failure, tamponade, or impending airway obstruction.

• Platypnoea
  Dyspnoea relieved by recumbency, generally due to intracardiac (right-to-left) or intrapulmonary shunts that are worsened due to the ↓ in West Zone 3 that occurs in the upright position.
  
  
• Centralisation
  Re-distribution of central blood volume away from the peripheries, leading to:
  • Extensive mottling
  • Diaphoresis
  • Piloerection
  • Cold skin
  • Loss of peripheral pulses
  • Confusion secondary to cerebral hypoperfusion

Centralisation

• Peripheral perfusion
  ↓ Peripheral blood flow occurs early in most shock states, leading to ↓ capillary refill and temperature. Caveats include:
  • Feet are typically affected earlier than hands
  • Localised hypo-perfusion
    • Vaso-occlusive disease
    • Embolism
  • Environmental temperature
    Central capillary refill is less affected by environmental conditions but is prolonged only in severe hypoperfusion; consequently it is much more specific although less sensitive.
    
    
• Livedo reticularis
  Lace-like mottling of the skin occurring due to hypoxaemia in vessels along the watershed margins between regions supplied by different ascending arterioles. May occur due to:
  • Vasospasm
  • Thrombosis
  • Hyperviscosity

Livedo reticularis

• Pitting oedema
  Pitting oedema occurs due to extravasation of fluid into the interstitium. In general:
  • Subjectively puffy fingers is the earliest sign
  • Clinically detectable oedema requires a 2-3L ↑ in extracellular fluid volume
  • Cardiac oedema is:
    • Symmetrical
    • Generalised
    • Dependent
      • Ankles and legs in ambulant patient
      • Sacrum and thighs in bedridden patient
  • Generalised oedema:
    • Occurs with capillary leak associated with severe illness
    • May occur at the trunk before spreading peripherally

Pitting Oedema

Neurological

• Hoarse voice
  • Laryngeal trauma
    Intubation.
  • Localised neck swelling
    • Carotid surgery
    • ENT surgery
  • Laryngeal nerve injury
    • Brainstem pathology
      • Stroke
    • Thyroid surgery
    • Aortic aneurysm
    • Aortic dissection
      
      
• Slurred speech
  • Cranial nerve injury
    • Stroke
  • Cerebellar injury

An Overview of Aphasias

Type	Fluency	Comprehension	Repetition
Broca’s aphasia	-	Yes	Yes
Wernicke’s aphasia Deafness	Yes	No	Difficult
Conduction aphasia	Yes	Yes	No
Transcortical motor aphasia	No	Yes	Yes
Transcortical sensory aphasia	Yes	No	Yes

Renal

• Volume state assessment
  Challenging, with very few accurate determinants.
  • Daily weighing is the most useful method to determine fluid loss and gain
  • Specific features of hypovolaemia:
    • Dry gingivolabial fold
    • Dry axillae
    • Skin turgor
      Non-specific in geriatric patients.

Dehydration refers to a reduction in total body water, and should be distinguished from hypovolaemia.

Gingivolabial Fold

Gastrointestinal

• Foetor hepaticus
  Smell of rotten eggs and garlic on the breath due to dimethyl sulphide accumulation, indicating portosystemic shunting.

Integumentary

• Petechiae
  Small (<2mm), non-blanching, red lesions that occur in dependent areas due to extravasation of erythrocytes through capillary venules.
  
  
• Purpura
  Larger non-blanching lesion due to coalescence of petechiae.
  
  
• Erythema gangrenosum
  Rare skin lesion that begins as a raised red-purple rash that progresses to deep ulceration with central necrosis, associated with:
  • Rheumatological and immune disease
    • Inflammatory bowel disease
    • Rheumatoid arthritis
  • Haematological malignancy
  • P. aeruginosa infection
    
    
• Drug exanthem
  Maculopapulous, confluating rash. May be with or without urticaria.
  
  
• Toxic epidermal necrolysis
  Diffuse large bullae and erosions on skin and mucous membranes.
  
  
• Erythema multiforme
  Immune-mediated rash characterised by ‘target’ lesions, precipitated by:
  • HSV
  • Medications
  • Vaccinations
    
    
• Candidiasis

Petechiae

Erythema Gangrenosum

TENS

Erythema Multiforme

Candidiasis

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References

1. Foot C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine. Elsevier Australia; 2011. (Examination series).
2. Dünser MW, Dankl D, Petros S, Mer M. Clinical Examination Skills in the Adult Critically Ill Patient. Springer International Publishing; 2018.