This hot case can be divided into two compartments:
Previous hot cases with this sort of theme to them can be found below.
The standard introduction
Ask examiners about turning up the lights
The physical examination
The details of this section can be seen in the opposite column.
The obs and investigations
The Physical Examination in Brief Detail
Ask the examiners to sit the patient up
Ask the examiners about any language barriers
Ask examiners to lay the patient flat.
One can ask the examiners the following questions:
One should ask about the following parameters:
One should ask to look at the pressure-volume loops.
There may be surgical drains (what is in them? How much of it?). Asking how much has been coming out may be relevant in a hot case which focuses on the diagnosis of a shock state.
The pleural catheters are also interesting. One should make a mental note of whether the ICCs are on free drainage or on suction. The content of these drains could be informative, especially if one notices blood or chyle.
A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:
These questions may go unanswered.
The patient you are examining may have some sort of extra gadget hooked up. If ECMO is in progress, one may wish to ask about the following parameters:
If IABP counterpulsation is in progress, it raises additional questions. One may wish to ask the examiners whether one may be able to switch it to 1:2, to assess the efficacy of augmentation.
This stage is critically important. The drug and fluid infusions which are currently in progress give a clue as to what problem is currently being addressed. One should not neglect the labelled bags; the choice of antibiotics gives one some idea of where the source of sepsis is thought to be.
TPN and trace elements may be a relevant feature.
Note the type and rate of any nutritional supplement, as well as any electrolyte infusions (is refeeding syndrome being managed?)
One should observe the following features of an EVD:
A metabolic cart may have been parked in the room.
What for, one could only guess.
Ideally, one should get the patient sitting up to 30-45°. This may not be possible. However, one should still ask for it.
Ideally, the patient should be exposed from the waist up. The candidate can then stand back and look for anything externally obvious:
Performing the GCS should be the first step, unless you notice that a neuromuscular junction blocker is among the infusions. The level of consciousness then determines how you go about examining the rest of the patient.
A traditionalist, who is examining Mr Bloggs, would approach the GCS in the following manner:
One has just performed a GCS assessment; one is still holding the hands.
Now, time to look at them more closely.
First, one should spent a second assessing whether they are warm or cold.
Then, one can focus on the nails. Nail signs are numerous and deserve their own page. In malnutrition, the nails and hair are good markers of long term protein nutrition, and could yield a lot of information. If a characteristic nail sign of malnutrition is missed, the examiners would be very disappointed.
In brief, the nail signs one could look for are as follows:
Done with the nails, one may want to briefly consider (and maybe even comment upon) the presence of any sort of characteristic deformities, eg. assymetrical wasting of the small muscles, or the joint changes of rheumatoid arthritis.
Next comes the pulse. While one still has both of the patient's hands, one ought to try to compare the radial pulses. It would be worthwhile to look up at the arterial line trace at this stage.
Tone of the upper limbs
Move up from the hands. While you are still holding the hands, you can perform a sort of gross examination of tone by pronating and supinating the wrists, and by flexing and extending the elbows.
One can appreciate the wasting of the biceps and triceps while doing this manoeuvre.
In the conscious patient, it may be possible to assess asterixis by asking the patient to hold both their arms up with the wrists dorsiflexed. Chronic alcoholism may be associated with both malnutrition and with chronic liver disease.
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Massive lymphadenopathy associated with malignancy would be an embarrassing missed feature of cachexia.
Palpate the neck:
The face may yield many helpful signs to guide the candidate:
The examination of cranial nerves is not an essential part of the malnutrition work-up.
However, it would be worthwhile to assess the mechanisms of swallowing, as this may be responsible for a chronically poor oral intake.
The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:
The Yankeur sucker is used to probe the posterior pharynx, on both sides. A gag reaction should result from this.
This collectively tests CN X and IX.
While on the subject of CN X, one may test the cough reflex by suctioning the trachea.
This tests CN X.
This is also a convenient time to ask about the volume and character of the secretions.
The conscious patient is asked to protrude their tongue, and move it from side to side.
This tests CN XII.
The uvula deviates away from the lesion.
This tests CN X and IX.
During the cranial nerve examination, one will inevitably end up tripping over the endotracheal tube. One should note whether there is anything unusual there; for instance, is there haemoptysis associated with malignancy or tuberculosis?
One should take note of the NG tube.
One puts both their hands on the chest to assess the symmetry of chest expansion.
One might wish to percuss the chest. If this is done in a slick fashion, it can be forgiven.
Changes in percussion resonance may be worth commenting on.
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.
The clever candidate will make a big show of palpating both the apex and the right sternal edge.
One should auscultate in the following sequence:
The various clicks and murmurs one encounters are discussed elsewhere.
For this, one should ask to lay the patient flat.
There may be old surgical scars or feeding tubes, which might suggest that this patient has a shortened gut.
There may be a stoma to examine.
The pelvic content would have been palpated during the abdominal examination.
The more important part of this examination is the groin.
At this stage, the patient should be re-draped - cover them from the waist up, and uncover their legs.
Observation and palpation of the pelvis:
Examination of the lines
Examination of the genitals and rectum
Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.
One should ask to remove TEDs and compression stockings.
Leg muscle tone
The best way to test muscle tone is by holding the knee. Roll the knee gently to distract the patient; then try to lift it off the bed. In the presence of increased tone, the leg will remain straight and the whole thing will lift up; with normal or decreased tone, only the knee will bend
In the conscious patient, one might be able to assess whether a gentle calf squeeze produces the characteristic pain which suggests a DVT may be present.
This brings one to the feet, and to the beginning of the neurological examination.
The feet would have already been palpated to assess their temperature, and to look for pitting oedema.
Observation of the feet
One should look specifically for changes suggestive of chronic diabetic foot disease, or chronically poor vascular supply.
Palpation of the feet
This should consist of palpating the dorsalis pedis and posterior tibial pulse.
One should test the Babinsky bilaterally.
One should attempt to assess clonus in both feet.
Now is the time to properly start the neurological examination of this patient.
Power of the muscle groups may be tested in the following sequence:
Now that one is back to the upper limb, one may as well start their reflex tests there.
The reflexes may be tested in the following order:
After testing the ankle jerk reflex, one is again back to the feet.
At this stage, with a conscious patient, one may wish to test light touch sensation.
The following order (with corresponding dermatomes) is suggested:
One is looking for characteristic glove-and-stocking sensory loss of B12 deficiency.
Ask to see the obs chart. If it is not allowed, ask for the following:
One may also wish do demonstrate an interest in the trends of any sort of advanced haemodynamic monitoring, eg. cardiac index as measured by PAC or PiCCO
One needs to show an interest in the following labs:
One should always ask for the following:
You sometimes want to see the following:
"Mr Bloggs is suffering from severe malnutrition, complicating his [insert critical illness here]."
"In my examination, I have discovered the following findings supportive of this diagnosis: [insert clinical findings here]"
"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"
"The current nutritional management issues are as follows: [a brief list of management priorities]"
"I would approach the management of this patient's nutrition in the following manner: [list of management strategies; it helps to organise this into an A,B,C,D,E approach if one has a complex multisystem problem to manage]"