This hot case frequently takes the form of a quest, to find the source of sepsis.
Generally speaking, there may be numerous reasons for fever:
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.
Sit the patient back up again
One should pay attention to the temperature reading, if it is being constantly monitored
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.
Weird ventilation strategies might suggest a pulmonary source of infection.
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:
The CRRT may suggest that the patient has severe sepsis, or that the patient is a recipied of chronic haemodialysis who has developed a more trivial sort of sepsis.
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.
If this is in progress, one can assume the fever has reached 40-41°.
Active cooling is rarely required for septic patients; however, in the context of brain injury and centrally-driven fever, this may be the only way to control the temperature.
This stage is critically important. The drug and fluid infusions which would be worth noting are:
One should observe the following features of an EVD:
Later, one should remember to ask for the CSF cell count and culture.
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:
First, one should spent a second assessing whether the hands are warm or cold.
Hand and hail signs one is particularly interested in during the febrile hot case:
Nail signs in general are discussed in greater detail elsewhere.
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; abnormalities such as the widened pulse pressure of aortic regurgitation may not have been noticed until 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.
Hypertonia globally may be a feature of neuroleptic-malignant syndrome.
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
One should ask the examiners whether it is possible to flex the neck, to examine for meningism. This is a crucial step, and one which may determine the character of the subsequent discussion.
It would be embarrassing to miss meningism in the examination of the febrile patient.
On the way up to the face, one should feel the temporal arteries. Vasculitis is a cause of fever, and its many manifestations may have been lost among the spectrum of ICU-related skin problems.
This section can be divided into three broad groups, according to the level of consciousness:
|The paralysed patient||The unconscious patient||The awake patient|
A sophisticated and detailed cranial nerve examination is desirable, but impossible within the timeframe permitted by the hot case. The following list of brief cranial nerve examination techniques is an attempt to abbreviate the formal sequence of testing to fit within
One can derive a substantial amount of information from the size of the pupils.
Hugely dilated pipils suggest serotonin syndrome.
Tiny constricted pupils may reveal anticholinergic syndrome as the cause of the hyperthermia.
Anticholinergic syndrome is also characterised by the failure of accomodation. These people will not be able to focus on near objects. however, asking the delirious anticholinergic overdose patient to focus on anything is an exercise in futility.
In the context of an unconscious patient with a fever, one may wish to perform fundoscopy. Not only is one looking for the characteristic bulging disk of increased intracranial pressure, but one may also find retinal involvement from systemic candidiasis.
Ask the examiners to dim the room lights.
Open both eyes. Each eye is exposed to light. The opposite pupil should constrict consensually.
This tests CN II (afferent) and CN III (efferent).
The conscious patient will be able to follow the tip of the candidate's finger.
The pattern of movements should be tracing the six cardinal points: superior left, inferior left, superior center, inferior center, superior right, inferior right.
This tests CNs II, IV and VI.
Nystagmus in eye movements may suggest alcohol withdrawal as a cause of the fever.
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.
An additional reason to poke around in the mouth is the potential for oral or pharyngeal infection as the cause of fever. One may discover a tonsillar abscess or a dental infection.
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. Sputum is an important clue to the
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.
One puts both their hands on the chest to assess the symmetry of chest expansion.
One might wish to percuss the chest.
Changes in percussion resonance may be worth commenting on.
An empyema, pneumonia or pleural effusion may be uncovered in this fashion.
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.
Specifically, one would be looking for a pericardial effusion, or a rub of pericarditis.
For this, one should ask to lay the patient flat.
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.
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. Ulcers on the heel may be concealed by dressings; one should ask what is under the dressings, and whether one can take a look.
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. Clonus is a feature of serotonin syndrome; whereas neuroleptic malignant syndrome only has generalised rigidity.
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:
Time to sit the patient back up again.
Reflexes may be exaggerated in serotonin syndrome, whereas in neuroleptic malignant syndrome the reflexes are depressed.
The reflexes may be tested in the following order:
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:
It might be interesting to ask about the lipase levels in the abdominal/pleural drain fluid.
One should also ask about any recently commenced medications, and about any recent anaesthesia.
One should always ask for the following:
You sometimes want to see the following:
"The source of Mr Bloggs' sepsis is [insert clever diagnosis here]."
"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"
"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"
"The current management issues are as follows: [a brief list of management priorities]"
"I would approach the management of these issues 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]"
"My choice of antibiotics in this case would be guided by the susceptibilities of the organism. Classically, such infections respond well to [antibiotic cocktail]."
"Given the degree of immune dysfunction, I would broaden the cover by including antiviral and antifungal agents".
”This is a complex case and I’m not certain of the diagnosis. Though I suspect sepsis, the alternative possibilities include [insert differentials]".
"I note the following features, supporting the diagnosis of sepsis [relevant features]"
"Additionally, I have identified the following clinical findings, which are not explained by this hypothesis:[insert list of findings]."
"I also note the following organ failures: [list organ problems]."
"The possible aetiologies responsible for these findings could include [list of differentials]".
"In order to discriminate between these differentials, I would like to perform the following investigations: [list of investigations]"
"Furthermore, I would like to enlist the help of the following specialties [insert list of consults], for whom I will have the following specific requests/questions: [what questions will you ask these specialist teams]"
"While suspecting sepsis, I would be inclined to use broad antimicrobial cover, consisting of [insert any cephalosplattin/murderpenem]"