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:

• Weaning from ventilation, and management of bronchospasm and hypercapnea
• Ventilation strategy
• Thoughts about when to offer a tracheostomy, or whether to offer it
• Management of malnutrition
• Management of associated illnesses (eg. IHD, CCF, pulmonary hypertension)

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

Examination of the COPD Patient

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 - NAVA, spirometry, RSBI... Urine catheter Drains (surgical, intercostal, etc) Dialysis Infusions   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 "This COPD patient's stay in ICU is complicated by ..."

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 Cranial nerves and the airway 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, and ask about performing a PR 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

The standard introduction

• The examiner will give you a history.

The prelude to the dance

• Wash hands.
• Gown and glove.
• 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 - this could be very important; make a mental note of the EtCO₂ waveform morphology. Is there a sawtooth pattern of bronchospasm?

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.

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/V_T.

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)

Urine catheter

• Unusual colour
• Anuria

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?

These questions may go unanswered.

Infusions

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.

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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)

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.

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.

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.

Poor tone in the upper limbs may be an indicator of a global weakness.

Asterixis

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.

Cubital fossa

Examine the cubital fossa for

• Peripheral lines
• Evidence of multiple venepunctures
• 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
• 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

Cranial nerves and the airway

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:

• Facial movements
• Gag reflex

• Cough reflex
• Tongue movements
• Uvula deviation

Facial movements

The conscious patient will be able to perform a series of grimaces to assess the bilateral motor control of facial muscles:

• Raise eyebrows to wrinkle forehead
• Squint eyes to assess periorbital muscles
• Bare teeth to assess nasolabial muscles
• Blow out cheeks

 

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.

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.

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.

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.

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.

Auscultation:

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.

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.

One should dedicate extra time to the examination of the rigt heart, focusing on features of pulmonary hypertension:

• The Graham Steell murmur of pulmonic regurgitation
• Loud P2
• Right ventricular heave
• Tricuspide regurgitation
• A characteristic CVP waveform for TR may be obvious.

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.
  • The patient with decompensated right heart failure will potentially have an enlarged congested liver with portal hypertension.
• 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.

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?

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.
• 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

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 wasting - especially of the quads- is an important feature of malnutrition. Additionally, one gets to appreciate the temperature difference between the limbs, which could be important in the assessment of peripheral vascular disease.
• Pitting oedema should be palpated.

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

Calf tenderness

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.

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.

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.

Power in the 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.

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.

Power in the upper limbs

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:

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

Reflex testing

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:

• 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 - this is going to be the most important feature
• Routine bloods
• Urinalysis
• Culture results
• Case-specific bloods, eg. CK, troponin, LFTs, pancreatic enzymes, inflammatory markers...
• Pre-admission "healthy" spirometry findings would be useful.

One may wish to ask the examiners about the premorbid exercise tolerance and degree of independence, as well as home oxygen use.

Imaging and other investigations

One should always ask for the following:

• ECG
• CXR

You sometimes want to see the following:

• CSF analysis
• CT or MRI results

 

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

"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]"