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.
