The most important issues to identify are:
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
A CTG monitor may be present. One should look at it knowingly; and then ask the examiners what it has been showing.
Also, early in the dance one should ask about the gestational age.
A pacing box?
Sensitivity and pacing threshold may not be relevant.
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.
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.
Important infusions to note:
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 Mrs 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 cranial nerves in the conscious obstetric patient should be limited to the eyes. PRES, sometimes associated with the hypertensive diseases of pregnancy, may have resulted in visual loss.
Thus, ones examination of the cranial nerves should focus on
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).
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?
It would be worthwhile asking what the grade of intubation was, demonstrating an awareness of difficult intubation in pregnancy.
One puts both their hands on the chest to assess the symmetry of chest expansion.
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.
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases. If there is aspiration pneumonia, one must find it.
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
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 reflex testing is of greatest importance if the patient is on a high-dose MgSO4 infusion.
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:
One should always ask for the following:
You sometimes want to see the following:
"Mrs Bloggs is suffering from [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 pregnancy is [progressing in spite of these issues / is threatened by critical illness]"
"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]"
”Mrs Bloggs is a X yr old pregnant woman with multiple problems."
"I note the following organ failures: [list organ problems]."
"I have identified clinical findings which support this hypothesis: namely, [insert list of findings]." "The possible aetiologies responsible for this presentation could include [list of differentials]; specifically, in the context of pregnancy, I am concerned about [blah]"
"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]"