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:

• Vasculitis
• Infectious disease
• Neoplasm (eg. leukaemia)
• Drug-related (eg. "drug fever", neuroleptic malignant syndrome, serotonin syndrome, or malignant hyperthermia following anaesthesia)
• Intracranial (eg. centrally-driven fever following SAH, or hypothalamic dysfunction)
• Trauma-associated (due to massive transfusion)
• Endocrine hyperthermia (eg. hyperthyroidism)
• Environmental hyperthermia (eg. heat stroke)

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

Examination of the Critically Ill Patient with Unexplained Fever

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 "I know the diagnosis" "I have no idea what is going on"

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 Look for meningism! Pay attention to the lines! Feel the temporal arteries Pupils, cranial nerves and the airway Ask to perform fundoscopy 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, Ask about performing a PR Ask about performing a PV (tampon) Pay attention to the lines! Legs: oedema and calf compressors. Leg muscle tone. Feet and Babinsky; clonus. Dorsi/plantarflexion power, knee and hip power Sit the patient back up again Hand, wrist, biceps, shoulder and shrug power Reflex testing, in hand-to-foot order Sensory testing, 13 points in foot-to-hand order Cerebellar exam of upper limbs and torso

The standard introduction

• The examiner will give you a history.

The prelude to the dance

• Wash hands.
• Gown and glove.
  • Observe: there may be purple cytotoxic bins in the room; you may be asked to wear cytotoxic precaution gear. Suddenly, you realise this febrile patient is probably on chemotherapy. Febrile neutropenia questions arise. Reverse barrier precautions (eg. masks in addition to gloves and gowns) confirm this suspicion. You don't even need to ask for the white cell count.
• 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
• Rate
• 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

One should pay attention to the temperature reading, if it is being constantly monitored

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.

Weird ventilation strategies might suggest a pulmonary source of infection.

Urine catheter

• Unusual colour
• Anuria
• Cloudyness or precipitate

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?

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.

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.

Active cooling

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.

Infusions

This stage is critically important. The drug and fluid infusions which would be worth noting are:

• Vasopressors/inotropes
• Antibiotics (duh)
• Nimodipine (SAH)
• Blood products

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?

Later, one should remember to ask for the CSF cell count and culture.

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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, obesity
• The evidence of trauma, wound dressings, etc
• The pattern of breathing (eg. whether there is a characteristic chest flail)
• Rash of vasculitis
• Abscesses/debridement sites of necrotising fasciitis

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.

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:

• Splinter haemorrhages
• Janeway lesions
• Osler's nodes
• Features of rheumatoid arthritis (which suggests chronic immune suppression)

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.

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.

Hypertonia globally may be a feature of neuroleptic-malignant syndrome.

Cubital fossa

Examine the cubital fossa for

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

One should then palpate the axillary lymph nodes.

The Neck

• Inspect any central lines. This is very important! Later, one needs to mention them as either something you are considering as a source of sepsis, or something that is plainly not the source of sepsis.
• It is important to ask the examiners: How old is this line?
• Look again at the CVP

Palpate the neck:

• Trachea: is it midline? Is there a new tracheostomy there?
• Thyroid gland
• Cervical lymph nodes
• Carotid pulse - one side at a time!
• Submandibular lymph nodes
• Pre- and post-auricular lymph nodes

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.

Pupils, cranial nerves and the airway

This section can be divided into three broad groups, according to the level of consciousness:

The paralysed patient	The unconscious patient	The awake patient
Pupil size Light reflex	Pupil size Light reflex	Pupil size Light reflex Eye movements and nystagmus
	Gag reflex Uvula deviation Cough reflex	Gag reflex and oropharyngeal examination Cough reflex Tongue movements Uvula deviation

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

Pupil size

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.

Light reflex

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).

Eye movements and nystagmus

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.

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.

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.

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. Sputum is an important clue to the

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.

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.

Changes in percussion resonance may be worth commenting on.

An empyema, pneumonia or pleural effusion may be uncovered in this fashion.

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.

Specifically, one would be looking for a pericardial effusion, or a rub of pericarditis.

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).

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.
• One should ask to roll the patient over, to look for pressure areas.

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. I
• 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 melaena or hard stool
  • Presence of blood or mucus
  • Quantity and character of diarrhoea.
• One should also ask about performing a PV. Once refused, one should ask whether the possibility of a retained tampon has been explored.

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 compartment tightness may suggest that rhabdomyolysis is the cause of the SIRS-associated fever.
• Pitting oedema should be palpated.
• Test leg muscle tone
• Look for calf tenderness

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. 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.

Babinsky reflex

One should test the Babinsky bilaterally.

Clonus

One should attempt to assess clonus in both feet. Clonus is a feature of serotonin syndrome; whereas neuroleptic malignant syndrome only has generalised rigidity.

Power in the upper and lower 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.

Time to sit the patient back up again.

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

Reflex testing

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:

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

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

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; specifically, one is looking for the full blood count, which contains a white cell count and eosinophil count.
• Urinalysis
• Culture results or at least the gram stain
• Case-specific bloods:
  • CK
  • LFTs
  • pancreatic enzymes
  • inflammatory markers
  • results of the vasculitic screen.

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.

Imaging and other investigations

One should always ask for the following:

• ECG
• CXR

You sometimes want to see the following:

• CSF analysis and culture result
• CT or MRI results

 

Case presentation and discussion: when you have a good idea of what is going on

"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]"

If relevant:

"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".

Case presentation and discussion: when you don't have a clue

”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]"