The patient may be jaundiced, recovering from liver transpalnt, waiting for one, or some combination of the above.
The objective of this hot case is to arrive at a conclusion at the end, as to how one might categorise this hepatic jaundice:
Previous hot cases with this sort of theme to them can be found below.
The standard introductionAsk examiners about turning up the lights The environment
The physical examinationThe details of this section can be seen in the opposite column. The obs and investigationsThe Presentation |
The Physical Examination in Brief DetailAsk the examiners to sit the patient up Ask the examiners about any language barriers
Ask examiners to lay the patient flat.
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Jaundice does not usually play interesting haemodynamic tricks. If one notices such tricks, something else is going on, and jaundice is merely the side-dish. One may have a severe cirrhosis which has decompensated due to SBP, for instance.
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:
The CRRT may suggest that the patient has severe sepsis, or that the patient is affected by hepatorenal syndrome. CRRT may also be used to clear lactate in patients with poor hepatic function.
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.
The possibility that the jaundice is being caused by mehanical haemolysis should be considered. One may even consider asking whether the patient was already jaundiced before the extracorporeal circuit was connected.
A MARS system may be by the bedside. It is unlikely to make an appearance, as the evidence for its use is weak.
A plasmapheresis system may be present, sugegsting an autoimmune cause of haemolysis (eg. TTP)
The patient may have a traction line attached to their Sengstaken-Blakemore tube, with a counterweight on the end.
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.
Patients with acute hepatic failure may require an EVD to assess and manage the increased ICP associated with acute pulmonary oedema.
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 jaundice hot case:
Nail signs in general are discussed in greater detail elsewhere.
Then, turn the hands over, to look for palmar erythema. Feel the radial pulse. It should be bounding and vasodilated. The patient should be warm.
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.
Cubital fossa
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
On the way up to the face, one should feel the temporal arteries; vasculitis may be a cause of jaundice.
The cranial nerves may not yield much in the examination of jaundice.
One may wish to perform a brief and focused examination:
Eye movements and nystagmus
Scleral icterus is said to be easier to detect than skin jaundice. However, generally speaking, if the patient is already jaundiced enough to become a CICM fellowship hot case, they will probably have a bilirubin so high that there is no additional diagnostic value in looking at the sclera. Do it anyway, and make it abundantly clear to the examiners that you are aware of it.
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.
Palpation:
One puts both their hands on the chest to assess the symmetry of chest expansion.
If gynaecomastia is present, one should make it obvious to the examiners that one is aware of it.
Percussion:
One might wish to percuss the chest.
Changes in percussion resonance may be worth commenting on.
A pleural effusion may be uncovered in this fashion; it may be the extension of ascites.
Auscultation:
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases.
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:
The various clicks and murmurs one encounters are discussed elsewhere.
Specifically, one would be looking for a pericardial effusion, or the right-sided "heave" suggesting that there is right heart failure. Tricuspid regurgitation might also be nice.
The mechanical click of artifical valves may alert one to the fact that the red cells are probably being eaten up by the leaflets.
For this, one should ask to lay the patient flat.
Abdominal observation
Abdominal palpation
Abdominal percussion
Abdominal auscultation
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.
Palpation of the feet
This should consist of palpating the dorsalis pedis and posterior tibial pulse.
Babinsky reflex
One should test the Babinsky bilaterally.
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.
A thorough neurological examination is probably not called for.
However, one may wish to perform the finger-nose test and the heel-shin test to assess the cerebellar dysfunction which might be associated with chronic alcoholism.
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:
Ascitic fluid results may be available.
It might be interesting to ask about the lipase levels in the abdominal/pleural drain fluid.
One should always ask for the following:
You sometimes want to see the following:
"The source of Mr Bloggs' jaundice 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]"
"I would approach the management of this issue 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]"
”This is a complex case and I’m not certain of the diagnosis. Though I suspect [hepatic failure, hamolytic anaemia], the alternative possibilities include [insert differentials]".
"I note the following features, supporting the diagnosis of blah [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]"
Number of previous hot cases in this topic: 8
Unspecified hospital in Adelaide |
62-year-old female, day 5 ICU, admitted with decreased level of consciousness from hepatic encephalopathy, secondary to decompensated liver disease with acute renal failure and haematemesis. Findings on examination included signs of decompensated chronic liver disease and hepatic encephalopathy, intubated on minimal ventilatory support and haemodynamic stability. Candidates were directed to provide a differential diagnosis for her decreased level of consciousness and to provide a management plan. Discussion points included interpretation of investigations, precipitants of hepatic encephalopathy and prognostication. |
St Vincent’s Hospital |
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Westmead Hospital |
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Flinders Medical Centre |
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Flinders Medical Centre |
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Austin Hospital |
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Royal Prince Alfred Hospital |
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Royal Prince Alfred Hospital |
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