This is the most generic of all hot case scenarios.
The objectives of examination are to go though all the systems and identify the reason the patient is still in ICU.
These could include:
The goal of discussion is to suggest strategies to manage these issues, and prepare for discharge.
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
At the ventilator, try to form an opinion about the ventilation wean. What has frustrated the weaning process?
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 patient's long stay in ICU may be because they are waiting for a transplant. One should be prepared to discuss fitness for heart/lung transplantation.
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.
The long stay patient may have absolutely no infusions running.
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:
Specific stigmata of long stay in ICU should be pursued:
Performing the GCS should be the first step.
The level of consciousness then determines how you go about examining the rest of the patient.
In general, the long stay patient will require a detailed neurological examination. One would not want to miss a high C-spine injury.
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 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; 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.
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.
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
The examination of the face and head is always affected by the level of consciousness.
The exact sort of examination one is able to perform is dependent entirely on the level of consciousness. A fully conscious extubated patient can perform the entire spectrum of cranial nerve tests; a deeply unconscious patient may have no motor response to pain, and one will be limited to testing the reflexes only; a paralysed patient won't even have those.
Thus, this section can be divided into three broad groups:
|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 is a short list of cranial nerve examination techniques.
The long stay patient may be "staying long" because of some sort of brainstem stroke, and this needs to be discovered by the candidate.
A Snellen chart is ideal, but probably will not be available.
The extubated patient should be able to read the time on the clock in the room.
One performs this test with each eye individually.
This tests CN II.
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 cornea (not the sclera) is touched lightly with a moistened corner of a piece of gauze.
A normal reflex is to blink.
This tests CN V (afferent) and CN VII (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.
Typically, this is performed by putting some pressure on the superior orbital notch.
The patient should either open their eyes or localise.
This tests CN V.
The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:
In the comatose patient, as the head is moved from left to right, the eyes should move in the opposite direction. A fixed unchanging gaze is a negative test; the reflex is not working.
This tests CNs III, IV, VI, and most importantly VIII.
Cold water is funneled into the patient's ear. A positive reflex consists of the eyes turning towards the chilled ear. This is a more potent stimulus for CN VIII than the oculocephalic reflex.
Now that one has finished with the upper cranial nerves, one can move on to the mouth, airway, and swallowing apparatus.
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.
The conscious patient is asked to shrug their shoulders against resistance.
This tests CN XI.
Thus, the whole process should look like this:
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 a dual-lumen tube, or a bronchial blocker?
A tracheostomy is a more likely airway ornament in these people. One should not whether it looks well healed (i.e. cronic, pre-dating the ICU admission) and whether it is on blow-over or T-piece.
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.
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.
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
Before you are done with the pelvis, you should find out
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:
The patient has spent most of this time flat and supine. Time to sit them back up again.
Power of the upper 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 should complete the exmaination with some cerebellar tests. This is unlikely to greatly aid the diagnstic process, but if you are lucky it will produce the impression of somebody who is thorough and systematic.
This would have become apparent during the testing of the eye movements.
This would have become apparent during the test for nystagmus
This is an assessment of coordination. The patient is asked to alternate between touching their nose and touching the finger of the candidate, who keeps changing its position.
The patient is asked to run the heel of one foot along the shin of the opposite leg.
Ask to see the obs chart. If it is not allowed, ask for the following:
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 remains in ICU because of several ongoing issues, of which the dominant is [insert clever diagnosis here]."
"I have come to this conclusion on the basis of the following findings: [insert clinical findings here]"
"His condition is [deteriorating / showing signs of slow improvement]"
"I would like to confirm my diagnosis with the following investigations: [insert appropriate investigations]"
"The other present issues are as follows: [a brief list of management problems]"
"In summary, barriers to discharge form the ICU are [blah]"
"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]"