This is a bog-standard ICU hot case scenario. The patient may be intubated, or (more likely) they will be on NIV. The major issues to consider in this hot case:
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 can ask the examiners the following questions:
One should ask about the following parameters:
One should ask to look at the pressure-volume loops.
For the NIV patient, it would be worthwhile to note the mask type and the degree of leak. One may wish to ask how often the patient is able to take breaks from NIV, how these breaks are tolerated, and what their degree of cooperation with NIV has been.
NAVA may be in use. One should look at the Edi and the NAVA assist level, to track the progress of the patient's weaning. The use of this srategy may point the candidate in the direction of neurological testing; this patient's weaning process may have been frustrated by muscle weakness.
One should also take particular note of the respiratory rate and the tidal volume, as these values can be used to calculate the rapid shallow breathing index: RSBI = RR/VT.
Thus, to use the Wikipedia example, a patient breathing at a rate of 25 with tidal volumes of 250ml has a RSBI of ( 25/0.25) = 100.
An RSBI less than 105 is generally considered an indication of a readyness to wean from ventilation.
One should ask about spirometry findings and peak flow measurements (if these are available)
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.
One may notice the infusion of an IV bronchodilator, or a bag of levosimenadan. Dexmedetomidine may be running, which might suggest that wearing the NIV mask has been an irritating chore for the patient.
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:
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:
Vertical nail ridges
Horisontal nail ridges
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.
Poor tone in the upper limbs may be an indicator of a global weakness.
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. This may indicate hypercapnea.
Examine the cubital fossa for
One should then palpate the axillary lymph nodes.
Palpate the neck:
The examination of the cranial nerves in the COPD hot case should focus on the readyness for extubation, or for weaning. This should probably be limited to the lower cranial nerves.
If the patient is on NIV, the candidate should ask the examiners whether it is appropriate to remove the mask briefly, to allow the assessement of the lower cranial nerves.
The following tests are relevant:
The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:
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.
At the airway of the intubated patient, one needs to ask about the volume and character of secretions. The ability to clear secretions will determine extubation success.
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.
In the COPD patient, air entry may be globally decreased, and there may be the fine velcro-like crackles of pulmonary fibrosis.
It would be important to pick this up; the examiners undoubtedly found this sign if it were present.
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.
One should dedicate extra time to the examination of the rigt heart, focusing on features of pulmonary hypertension:
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:
Because steroids are a mainstay of COPD treatment, one needs to spend some time on the examination of limb power, looking for steroid-induced myopathy.
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:
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 may wish to ask the examiners about the premorbid exercise tolerance and degree of independence, as well as home oxygen use.
One should always ask for the following:
You sometimes want to see the following:
"Mr Bloggs is suffering from an exacerbation of COPD, complicated by [add complicating features, eg. right heart failure, pneumonia, PE, MI]."
"This patient's COPD is [mild, moderate, severe]".
"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]"
"Issues which are complicating the weaning process are as follows: [VAP, muscle weakness, malnutrition, delirium, etc]"
"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]"
Number of previous hot cases in this topic: 2