Chapter 3. An introduction to clinical examination
Examination will be described in the order used in the standard approach which is a common theme throughout this book – the <C>ABCDE system.
No examination is performed without clues from the history and attention should be paid to other information such as mechanism of injury, patterns of vehicle damage and damage to protective clothing or helmets.
Often an assessment of A–D is made by a simple question: ‘Are you OK?’ If this elicits a response such as ‘Yes, but my ankle hurts’, this means the airway is clear, the patient is breathing enough to speak clearly, the brain is adequately perfused and the Glasgow Coma Score is either 14 or 15.
<C> is applied in cases of catastrophic haemorrhage where control of bleeding takes priority over the rest of the primary survey.
Airway
Possible abnormal noises originating in the upper airway include the following:
Gurgling
Gurgling suggests the presence of fluid in the airway, possibly blood, saliva or stomach contents that have been regurgitated. This will require suction.
Snoring
This is usually caused by the soft tissues of the nasopharynx and oropharynx flopping back against the posterior wall of the throat, partially obstructing the flow of air.
Stridor
Stridor is caused by partial blockage of the upper airway by swelling (due to burns, infection or anaphylaxis) or a foreign body.
Hoarseness
Hoarseness has many causes, all relating to pathology around the larynx and vocal cords.
A more formal visual inspection is then carried out to assess for swelling, the presence of a foreign body, trauma or bleeding that may compromise the airway. An assessment of the airway goes hand in hand with an assessment of breathing and if there is no evidence of breathing, airway opening manoeuvres should be performed to ascertain if there is respiratory effort.
Other features which should be sought when examining the neck are summarised in Box 3.1.
Box 3.1
• Tracheal deviation
• Swelling
• Surgical emphysema
• Wounds
• Distended neck veins.
Breathing
The assessment of breathing (and the respiratory system) should involve a four-stage process.
• Look
• Feel
• Auscultate
• Percuss.
Looking for visual clues
A great deal of important information can be gained from careful inspection of the chest:
• How hard is the patient working to breathe?
• Are there any external signs of injury such as pattern bruising or abrasions?
• What is the respiratory rate (normally 12–18/minutes)?
• Are there signs of respiratory distress?
• What is the position of the patient (the patient sitting forward using the arms to support the chest is in respiratory distress)?
If there is unequal movement of the chest, this suggests a problem on one side such as a pneumothorax, haemothorax or collapse of one lung.
General hyperinflation of the chest may suggest chronic obstructive pulmonary disease (COPD) or may occur in severe asthma.
Always count and record the respiratory rate.
DO NOT FORGET TO ADMINISTER OXYGEN.
Feel
Once visual inspection is complete, the chest should be palpated for equal expansion and, in trauma, for any evidence of tenderness over the ribs or sternum.
Auscultation
Problems include:
• Stridor – a harsh noise produced on inspiration, e.g. due to inhalation of foreign body, swelling due to airway burn, croup or epiglottitis
• Wheeze – a higher pitched noise on expiration due to obstruction lower down in the lungs in the smaller air passages
• Bronchial breathing – the noise that is transmitted from the larger airways through solid lung, the result of infection or collapse
• Crepitations – crackling sounds that are typically heard in the lung bases in the presence of pulmonary oedema.
During auscultation, the stethoscope should be placed on the front of the chest on both sides, in the axillae and at the bases.
Pulse oximetry should be considered routine in the examination of the sick or injured patient.
Percussion
Percussion is performed by tapping the end of the middle finger of one hand onto the middle phalanx of the same finger of the other hand, which should rest flat on the surface being examined. Use the tip of the finger and not the pad of the finger, and only one finger should be used as the ‘hammer’.
A more hollow (resonant) sound than normal suggests an air-filled cavity beneath; a dull sound suggests a solid organ (e.g. liver) and fluid is revealed by ‘stony’ dullness.
Circulation
After establishing the presence of a pulse, the next thing to do is establish its rate. This should be done by counting how many beats occur in a given time, usually 15 seconds, and multiplying by four to give a heart rate per minute.
The normal heart rate for an adult is 60–100 beats per minute (bpm). A pulse faster than 100 bpm is by definition a tachycardia.
A weak and thready pulse suggests a low blood pressure and a compromised cardiovascular state, whereas a strong and bounding pulse may indicate a hyperdynamic circulation and is found in conditions such as chronic lung disease and carbon monoxide poisoning.
Non-invasive blood pressure measurement and a three-lead electrocardiogram trace are also essential parts of the assessment of the circulation.
Disability
Disability assessment should include examination of the conscious level, pupils and gross motor function. The conscious level can be assessed quickly using an AVPU score or more thoroughly using the Glasgow Coma Score.
The AVPU score
The AVPU score is a quick and easy assessment of conscious level.
• A – alert
• V – responds to voice
• P – responds to a painful stimulus
• U – unresponsive.
The painful stimulus should be applied above the clavicles, e.g. by applying pressure on the forehead. Pressure on a finger nail bed should not be used as no response would be elicited in a patient with a spinal injury.
The Glasgow Coma Score
The Glasgow Coma Score (GCS) is used to make a more formal assessment of conscious level during the secondary survey. It involves three components: the eye opening (E), verbal (V) and motor (M) responses, as outlined in Box 3.2.
Box 3.2
Eye opening response
| Spontaneous | = | 4 |
| To verbal stimuli | = | 3 |
| To painful stimuli | = | 2 |
| No response | = | 1 |
Best verbal response
| Orientated | = | 5 |
| Confused | = | 4 |
| Inappropriate words | = | 3 |
| Incomprehensible sounds | = | 2 |
| No response | = | 1 |
Best motor response
| Obeys commands | = | 6 |
| Localises pain | = | 5 |
| Withdraws from pain | = | 4 |
| Abnormal flexion | = | 3 |
| Abnormal extension | = | 2 |
| No movement | = | 1 |
When handing over information about a GCS, it should always be broken down into its three components (e.g. ‘a GCS of 8 with E2 V3 M3’).
Pupil response
After an assessment of conscious level, the pupils should be examined with a bright light source.
• The size, symmetry and reaction to light should be assessed
• The pupils should constrict equally to a light stimulus
• A unilateral dilated unreactive pupil may be a sign of III cranial nerve damage due to intracranial swelling or haematoma on that side (a late sign)
• Bilateral pinpoint pupils may suggest administration of opiates and dilated pupils can be the result of drugs or activation of the sympathetic nervous system.
The signs of rising intracranial pressure are:
• Bradycardia
• Hypertension (blood pressure falls as a pre-terminal event)
• Alteration in conscious level
• Unilateral then bilateral pupillary dilation
• Irregular ventilatory pattern
• Dysrhythmias (preterminal).
Finally, a gross assessment of peripheral motor and sensory function can be made by asking the patient to clench the fists and wiggle the toes and whether she/he can feel you touching his/her hands and feet. In this way, a map of normal sensation over the body can be made and should be documented.
In the case of stroke, one side of the body may be paralysed, or in the case of spinal injury, there will be loss of sensory and motor function below the level of injury.
Examination of the limbs
Each limb should be examined in turn, using the following method:
• Look for bruising, swelling or deformity
• Actively move (patient moves each joint)
• Passively move (practitioner moves each of the joints in the affected limb)
• Feel for swelling, crepitus, bruising and tenderness.
For further information, see Ch. 3 in Emergency Care: A Textbook for Paramedics.
