Physical Exam Key Points

1. Vital signs. High fever by itself may cause vasodilation and hypotension and should be treated with antipyretics and active cooling. If present, it should increase suspicion of a more serious infection. If patient is tachypneic without evidence of pulmonary disease, consider the presence of metabolic acidosis and an attempt by patient to compensate with respiratory alkalosis. See also earlier discussion at II, A, regarding heart rate and BP.

2. General appearance. Does patient appear toxic? Is patient in distress? If so, consider serious infections and prepare to be more aggressive in therapy.

3. Skin. Patients in hypovolemic shock have cool, clammy skin. Look for rashes (eg, petechiae or purpura, or a diffuse erythematous rash) that may be indicative of more serious infections.

4. Neck. Look for jugular venous distention as evidence of right heart failure, tension pneumothorax, or pericardial tamponade.

5. Heart. Listen for heart sounds. If sounds are muffled, or a rub is present, consider pericardial effusion. Gallop is indicative of cardiac dysfunction. Examine ECG tracing to be sure tachycardia is sinus and that no other rhythm disturbance is present (especially supraventricular tachycardia).

6. Lungs. Unilateral decreased breath sounds may be indicative of pneumothorax, pleural effusion, or consolidation. Listen for crackles or rales, which are indicative of pneumonia.

7. Abdomen. Distention, tenseness, guarding, and hypoactive or absent bowel sounds may indicate an acute abdomen. Peritonitis with subsequent fluid sequestration may be present.

8. Extremities. Assess hands and feet to see if they are cool or warm. Often, if resuscitation is not yet adequate, a line of demarcation from cool to warm can be noted, and this line travels more distally until it disappears as patient is resuscitated. Assess capillary refill. If delayed, continue resuscitation. Evaluate for presence of edema that may be indicative of third spacing.

9. Neurologic exam. Although last in this list, this should be the first thing assessed in physical exam. Decreased mental status indicates inadequate cerebral perfusion and requires emergent attention and treatment with aggressive fluid resuscitation and consideration of airway protection.

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