Physical Exam Key Points

1. General appearance. Mottled, cool, or clammy skin may indicate sepsis, a common cause of metabolic acidosis in the ICU setting. Fever typically also is present

2. Vital signs. Is there tachycardia, bradycardia, hypertension, hypotension, or any cardiac dysrhythmia? Peripheral vasodilatation? If present, reevaluate current support and check mechanical ventilator settings if patient is intubated.

3. CNS. There may be somnolence or obtundation, anxiety or confusion, psychosis, tremors, headache, or papilledema. In the absence of direct CNS injury, presence of these findings indicates inadequate cerebral perfusion or oxygenation, or both.

4. Lungs. Listen for decreased breath sounds, stridor, rales, crackles, or wheezes. If metabolic acidosis is present, compensatory mechanisms include deep, rapid respirations (Kussmaul breathing).

5. Cardiovascular findings. Cardiogenic shock may cause acidosis. Acidosis by itself may cause arrhythmias, reduce myocardial contractility, and decrease responsiveness to cate-cholamines.

6. HEENT. Tracheal shift may indicate tension pneumothorax; jugular venous distention is seen with tension pneumothorax or cardiac tamponade. Fetor hepaticus (halitosis of fruity odor) may suggest hepatic failure or diabetic ketoacidosis.

7. Abdomen. Distention, tenseness, involuntary guarding, or other peritoneal signs may indicate acute abdomen as the initial cause of acidosis.

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