Journal Of Paramedic Practice - Clinical exam: an introduction

Abstract

The clinical examination is an important part of any patient consultation. After the primary survey and patient history, a more in-depth examination of the patient is required in order to aid the working diagnosis and help negate other differential diagnoses. The extent of this depends on the stability of the patient condition and may not be possible in time-critical circumstances. However, it is becoming an increasing part of paramedic practice due to continued expansion of the scope of the paramedic role, both in urgent and emergency care. Educational delivery of clinical examinations of each of the main body systems is now an integral part of undergraduate paramedic curricula.

The forthcoming Clinical Examination series will provide a step-by-step overview for each of the main body systems. Continuing professional development (CPD) is an essential requirement for all clinicians in order to maintain and demonstrate currency and advancement within their roles (Health and Care Professions Council (HCPC) 2018). This series will therefore provide an overview of each examination to support students, newly qualified paramedics, and paramedics wishing to utilise these as a CPD development activity and an aide-memoire for clinical practice. This article will provide an introduction to the series, a guide to the intended use and an overview of initial examination considerations, including first impressions.

How to use these guides

The articles are intended to support clinician development and to assist in the overall assessment of patient presentations. The information should be used to support consideration of differential diagnoses in situations where life-threatening conditions have been ruled out. The extent and explanation of each examination will not be to the depth of those provided in core literature texts, so further reading and consolidation is advised to support understanding, supplemental to these articles. Key questions will be included for reader consideration and to direct further study.

Most examinations are taught in a very rigid format; however, in clinical practice, the clinician needs to be able to be flexible and adapt their approach depending on the presenting condition and circumstance. There is no single way to approach each of these examinations; however, working within a good structure will reduce omissions and errors, and support the gathering of information to inform patient care.

Contemporary texts will provide the underpinning reference sources throughout this series, as many of the examination processes and techniques are universally applied. Differences will however be highlighted. Readers will be signposted to these key texts for each clinical examination. The following systems will be included as part of this series:

Cardiovascular system

Peripheral vascular system

Neurological system (upper and lower limbs)

Cranial nerves

Gastrointestinal system

Respiratory system

Musculoskeletal system

Examination overview

The initial part of any patient encounter is a primary survey to assess for and manage any life-threatening presentations. However, if the patient is stable, either in the emergency or urgent care setting, the clinician should obtain a comprehensive history, followed by an examination to assist with and support their findings. Any form of secondary survey or examination is only applicable following completion of the primary survey (Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2019).

The clinical examination supports findings obtained from the patient history and the depth and focus of this examination will vary dependent on various factors (e.g. time, clinical presentation, location and environment). The importance of the patient history should not be underestimated, and most information can be obtained through effective questioning and exploration of the patient's primary complaint (Japp and Robertson, 2018). Furthermore, baseline observations provide essential insight into the patient's physiological status, either supporting a working diagnosis or ruling out other differential diagnoses (Bickley and Szilagyi, 2017). It is important to consider assessment of the following, in conjunction with the patient history and required system examination:

Pulse

Respiratory rate

Blood pressure

Blood glucose

Conscious level (Glasgow Coma Scale)

Capillary refill

Patient colour (pallor)

While each examination will be explored individually within this series, in practice, many do cross over. For example, examination of the chest (precordium) may entail listening for heart sounds and respiratory sounds. Examination of the hands, arms and face may elicit findings of abnormalities from various body systems.

Each examination is structured, with the respiratory, cardiovascular, abdominal systems following the Inspection, Palpation, Percussion and Auscultation cardinal format. However, Baker (2016) stipulates that for the abdominal examination, auscultation should be undertaken prior to palpation and percussion, as these manoeuvres may affect the bowel sounds. Keeping to a logical structure will provide readers with a guide, while ensuring omissions and errors are kept to a minimum (Douglas et al, 2013; Swartz, 2014; Bickley and Szilagyi, 2017).

General considerations

Paramedics should ensure they introduce themselves to the patient in a friendly and professional manner. This would normally occur at the very start of the patient consultation. Explain what you will be doing and gain consent from the patient (Bickley and Szilagyi, 2017).

Consider patient dignity throughout your examination and if exposing an area of the person's body, be sure to cover at the earliest opportunity avoiding unnecessary exposure—this not only maintains dignity and reduces the possibility of embarrassment, but also provides comfort. Patients may become anxious, so it is important to keep them informed and reassured throughout the examination (Bickley and Szilagyi, 2017). Furthermore, patient confidentiality should be maintained, with the examination undertaken in private where possible.

Awareness of cultural or religious differences should be respected, which may include consideration of the gender of the clinician examining the patient. This is not always possible in the out-of-hospital environment; therefore, provision of a chaperone when assessing a sensitive area of a patient should be considered. A chaperone may be a relative or a fellow clinician, and depends on the location of the examination. A record of the chaperone and their presence in the patient notes is best practice (Douglas et al, 2013).

Standard and universal infection control precautions should be maintained for patient examinations, with effective hand-washing and appropriate personal protective equipment considered.

Effective lighting cannot always be attained in the out-of-hospital environment; however, try your best to ensure appropriate lighting, and reduce external noise where practical (Swartz, 2014; Bickley and Szilagyi, 2017).

First impressions

A lot of information can be gathered from first contact with a patient. Emergency and urgent care personnel are fortunate to be able to view the scene and environment of the initial call, be it in the patient's home or another private/public location; therefore, it is important that any factors are identified, considered and recorded when assessing and evaluating the patient condition. First impressions may include:

Does the patient look well? From your experience, what is their demeanour? Are they alert? Do they appear in pain or distress? Note facial expressions and listen to their speech. Is their speech slurred or laboured?

Patient position What position is the patient in? Is this the most comfortable position for them? Is this the best position for them based on initial observations? How are they stood (if standing)? How do they move (if mobile)?

Colour Is there any evidence of central or peripheral cyanosis? Peripheral cyanosis is seen in the extremities and may be a sign of poor circulation or a cold environment. Central cyanosis (lips/tongue) is evidence of poor oxygenation and perfusion (Thomas and Monaghan, 2014). Cyanosis may be more difficult to see in patients with dark skin (Douglas et al, 2013). Is the patient flushed? Does the patient have any form of skin pigmentation caused by an underlying acute or chronic condition?

REFLECTION

What other forms of skin pigmentation are there and what conditions can they indicate? E.g. Jaundice

Bedside items Are there any items around the patient that may provide an indication of their underlying medical history? Items may include medication, inhalers, oxygen/nebuliser equipment, care plans, mobility aids, medic-alert cards (JRCALC, 2019)

Hydration status Are there any clues that could indicate an impairment of the patient's hydration status? These could include evidence of fluid loss or impairment, dry skin, catheterisation

Clothing/grooming How is the patient's appearance? Do they look like they have been looking after themselves? Do they have an unkempt appearance? Does this provide clues as to any underlying condition or self-neglect?

Home dwelling Are there clues in the house that could aid your working diagnosis, e.g. pet hair, damp/mould, tobacco smoke, mobility aids, bed position/location?

Odours Poor personal hygiene can lead to increased body odour. Odours can be a diagnostic tool (Bickley and Szilagyi, 2017). Are there any strong odours present? What could be causing these odours?

REFLECTION

What are the clinical causes of various odours (For example, fetor hepaticus, uraemic fetor, etc)

Eye contact Eye contact is a key communication tool. Lack of eye contact from a patient may provide an indication of their personal or psychological wellbeing. Direct eye contact may in some cultures be impolite; therefore, again, it is important to be aware of differences in culture and beliefs as part of your initial assessment.

REFLECTION

Consider a patient you have recently attended, making note of initial first impressions and the consideration of clues that could support a working diagnosis.

The aim of the clinical examination is to gather further information to support findings obtained from the patient history and clinical observations. Information gleaned can help inform the decision-making process when considering treatment and/or referral plans for patients in their care. All information should be recorded within patient documentation to enable effective continuity of care throughout the patient journey.

This initial introduction provides an insight into the beginning of the examination process, with key aspects to be considered, which will then lead into the subsequent system examinations explored within this series.