This hot case can be divided into two compartments:

• Finding the signs of macronutrient and micronutrient deficiency
• Discussing the management of this state

Previous hot cases with this sort of theme to them can be found below.

Examination of the Malnourished Critically Ill Patient

The standard introduction Listen to the introductory statement. Wash hands; don gloves and gown. Ask examiners about turning up the lights   The environment Monitoring Ventilator Urine catheter Drains (surgical, intercostal, etc) Dialysis IABP / ECMO Infusions EVD   The physical examination The details of this section can be seen in the opposite column.   The obs and investigations Temperature, urinalysis, drain output, urine output ABG, ECG, bloods, culture results CXR, CT images and CSF analysis. The Presentation "This patient is malnourished, because..."

The Physical Examination in Brief Detail Ask the examiners to sit the patient up Expose to the waist and observe. Ask the examiners about any language barriers GCS Hands, the nail signs, pulse and arterial line Arm tone and upper limb lymph nodes Neck lymph nodes, trachea, thyroid Observation of the face Pupils and the lower cranial nerves Ask about the sputum Chest palpation, percussion, auscultation, and ask to roll over Praecordium palpation, auscultation, and ask for Valsalva Ask examiners to lay the patient flat. Abdominal palpation, percussion, auscultation Pelvis: groins, lines, and ask about performing a PR Legs: oedema and calf compressors. Leg muscle tone. Feet and Babinsky; clonus. Power in the lower and upper limbs Reflex testing, in hand-to-foot order Sensory testing, 13 points in foot-to-hand order

The standard introduction

• The examiner will give you a history.

The prelude to the dance

• Wash hands.
• Gown and glove.
• Ask, if relevant:
  • "Can I turn on all the lights?"
  • "Are there any movement restrictions? Can I sit them up, or roll them on their side?"
  • "Is there a language barrier?"
• Introduce yourself: “Hi Mr or Mrs Bloggs, I’m Dr So-and-so. I’m going to examine you.”

The Monitors

• Rhythm - may be in AF
• Rate- may be bradycardic (tachycardia in anorexia is a bad sign, it suggests heart failure is imminent)
• Morphology: QRS width
• MAP and abnormal morphology of the arterial waveform
• CVP and abnormal morphology of the CVP waveform
• Ancillary waveforms eg. the PA catheter waveform
• Oxygen saturation measurement, and the quality of the waveform
• End-tidal CO₂ waveform and level - high EtCO₂ may suggest a hypercatabolic state

The Ventilator

One can ask the examiners the following questions:

• How are we oxygenating this patient?
• How are we ventilating this patient?

One should ask about the following parameters:

• FIO₂
• PEEP
• Peak pressure
• Plateau pressure
• Tidal volume and minute volume

One should ask to look at the pressure-volume loops.

Urine catheter

• Unusual colour
• Anuria - anorexic patients may have renal failure

Drains (surgical, intercostal, etc)

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.

Dialysis

A CVVHDF or SLEDD process may be in progress. The savvy candidate may wish to ask the following questions:

• Which modality is being used?
• What is the dose of dialysis?
• What is the rate of fluid removal?
• How is the circuit anticoagulated?
• How long has this filter lasted?

These questions may go unanswered.

IABP / ECMO

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:

• VA or VV?
• Flow rate
• Fresh gas flow
• Any recent problems with the circuit

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.

Infusions

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?)

EVD

One should observe the following features of an EVD:

• Set height
• Whether it is open or closed
• The CSF colour - eg. is it full of blood?

Weird machinery

A metabolic cart may have been parked in the room.

What for, one could only guess.

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The physical examination

Expose and observe

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:

• Skin colour, eg. jaundice or the discolouration of chronic renal failure
• Muscle wasting
• The evidence of trauma, wound dressings, etc
• The pattern of breathing (eg. whether there is a characteristic chest flail)

GCS

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:

• Grab hold of both of the patient's hands.
• "Mr Bloggs!" One pauses to observe for eye opening.
• "Can you squeeze my hands?"
• If hand squeezing and eye opening is not observed, one administers a painful nail bed stimulus to both hands, to observe the response to pain.

Hands, nail signs, pulse and the arterial line.

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.

Arms

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.

Asterixis

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.

Cubital fossa

Examine the cubital fossa for

• Peripheral lines
• Evidence of multiple venepunctures
• Lymph nodes
• Brachial pulse
• The presence of an obvious AV fistula

One should then palpate the axillary lymph nodes.

Massive lymphadenopathy associated with malignancy would be an embarrassing missed feature of cachexia.

The Neck

• Inspect any central lines
• Look again at the CVP
• Observe the prominence of the clavicles

Palpate the neck:

• Trachea: is it midline? Is there a new tracheostomy there?
• Thyroid gland: is it massively enlarged? Is hyperthyroidism the cause of this malnutrition?
• Cervical lymph nodes
• Carotid pulse - one side at a time!
• Submandibular lymph nodes
• Pre- and post-auricular lymph nodes

Observation of the face and head

The face may yield many helpful signs to guide the candidate:

• Horner's syndrome (malignancy)
• Wasting of the temporalis muscle (severe malnutrition)
• Periorbital tissue loss (sunken eyes)
• Poor dentition (Vitamin C deficiency)
• Glossitis and angular stomatitis (iron deficiency)

Pupils and the cranial nerves

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.

• Facial movements
• Gag reflex

• Cough reflex
• Tongue movements
• Uvula deviation

Facial movements

The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:

• Raise eyebrows to wrinkle forehead
• Squint eyes to assess periorbital muscles
• Bare teeth to assess nasolabial muscles
• Blow out cheeks

Gag reflex

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.

Cough reflex

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.

Tongue movements

The conscious patient is asked to protrude their tongue, and move it from side to side.

This tests CN XII.

Uvula deviation

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.

Chest palpation, percussion and auscultation

Palpation:

One puts both their hands on the chest to assess the symmetry of chest expansion.

Percussion:

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.

Auscultation:

One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.

Palpation and auscultation of the praecordium

Palpation:

The clever candidate will make a big show of palpating both the apex and the right sternal edge.

Auscultation:

One should auscultate in the following sequence:

• Apex
• Left sternal edge, lower
• Left sternal edge, upper
• Right sternal edge, lower
• Left sternal edge, upper
• Both carotids

The various clicks and murmurs one encounters are discussed elsewhere.

Abdominal palpation, percussion and auscultation

For this, one should ask to lay the patient flat.

Abdominal observation

• Take a moment to behold the abdomen. One may ask the examiners to look under any surgical dressings; one is likely to be denied this part of the examination (they will tell you the wound looks clean and dry).

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.

Abdominal palpation

• All quadrants should be palpated.
• Then, feel for the liver edge; observe respiratory excursion
• Then, feel for the spleen.
• Then, try to ballot the kidneys. Enquire about renal tenderness.

Abdominal percussion

• This can double as a test for peritonism.
• If there is some suspicion of ascites, one may ask to roll the patient, so shifting dullness can be better appreciated. The examiners may not permit this test.

Abdominal auscultation

• One should spend a good length of time on this, if one suspects bowel obstruction or ileus.

Examination of the pelvis and groins

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:

• There may be a rash of thrush, or a groin haematoma, or an external fixation device.
• The posterior pelvis and sacrum should ideally be palpated for pitting oedema.

Examination of the lines

• One should take notice of anything going into or coming out of the femoral vessels.
• There may be a vascath, a PiCCO catheter or some sort of angiography sheath. These are important clues. Why did this patient get an angiogram? What is the PiCCO for?

Examination of the genitals and rectum

• A complete examination would call for the palpation of the testes, and a comment on their size. However, this may not be practical.
• One should take note of any sort of waste management devices, eg. rectal tube, SPC or IDC.
• One should definitely ask about performing a PR.
• If one is forbidden from performing the PR, one should ask about the following features:
  • Anal sphincter tone
  • Size and quality of the prostate
  • Presence of diarrhoea, and its volume

Once one is finished with the pelvis, one should cover it again, so that only the legs are sticking out.

Examination of the lower limbs

One should ask to remove TEDs and compression stockings.

• One should observe whether the lower limbs are mottled, and whether they are of the same size (assymetrical swelling leads one to suspect lymphoedema or DVT)
• One should palpate the larger muscles. Muscle wasting - especially of the quads- is an important feature of malnutrition.
• Pitting oedema should be palpated. Chronic malnutrition may give rise to hypoalbuminaemic oedema.

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

Calf tenderness

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.

Feet and the Babinsky reflex

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.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet.

Power in the lower and upper limbs

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:

• Ankle dorsi and plantarflexion
• Knee flexion and extension
• Hip flexion, extension, adduction and abduction.

• Hand grip
• Wrist dorsiflexion/palmarflexion
• Elbow flexion/extension
• Shoulder adduction / abduction

Reflex testing

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:

• Brachioradialis
• Biceps
• Triceps
• Knee jerk
• Ankle jerk

Sensory testing

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:

• Sole of the foot (S1)
• Lateral lower leg (L5)
• Medial lower leg (L4)
• Medial knee (L3)
• Anterior upper quads (L2)
• Umbilicus (T10)
• Nipple level (T5)
• Medial forearm (T1)
• Pinky finger (C8)
• Middle finger (C7)
• Thumb (C6)
• Lateral forearm (C5)
• Posterior shoulder (C4)

One is looking for characteristic glove-and-stocking sensory loss of B12 deficiency.

The measured observations

Ask to see the obs chart. If it is not allowed, ask for the following:

• Trends of blood pressure and heart rate
• Temperature
• Drain output
• Urine output
• Daily nutritional intake (oral vs NG vs TPN)

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

The laboratory investigations

One needs to show an interest in the following labs:

• ABG
• Routine bloods - especially electrolytes - potassium and phosphate
• Urinalysis - particularly the ketones
• Culture results
• LFTs, pancreatic enzymes, inflammatory markers, intrinsic factor antibodies, iron studies, albumin and prealbumin level.

Imaging and other investigations

One should always ask for the following:

• ECG
• CXR

You sometimes want to see the following:

• CSF analysis
• CT or MRI results

 

Case presentation and discussion

"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]"