The patient has some sort of shock state. The examiners have launched you at it, to work out what is causing it in ten minutes.
One should keep mindful that there are only a few things it could be:
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 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:
Urine output is important. One should ask for the recent trends.
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 patient's shock state may have resulted in multi-organ system failure. One should view CRRT as a marker of severity. It would be worthwhile asking whether they were dialysis dependent before their admission to the ICU.
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 almost confirms cardiogenic shock. Nevermind that the patient may not be shocked any more - counterpulsation may have improved the situation - but reliance on 1:1 counterpulsation demonstrates a poor cardiac reserve. 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 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.
Vasopressors and inotropes are the key features here.
One may also wish to ask whether the patient has received any levosimendan in recent history.
One should observe the following features of an EVD:
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. This is of critical importance in the examination of the shocked patient. The question one answers is "is the peripheral perfusion satisfactory?"
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 arms:
Lymph nodes are very important here: they may give one the hint that not all is well with the immune system.
The cranial nerve exam is probably not going to be of great use in the diagnosis of undifferentiated shock.
One may wish to limit oneself to the following brief review:
The patient may give every sign of being brain dead, in which case one might want to perform some of the cranial nerve tests for brain death. Or they may be a cooled paralysed cardiac arrest survivor, in which case one may have nothing at all to find on neurological examination.
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 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.
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?
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.
Pulmonary oedema or ARDS will add to the picture of multi-organ system failure.
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.
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.
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.
Testing the limb power in an undifferentiated shock hot case is a matter of excluding central nervous system causes of shock, such as a spinal cord transection or epidural abscess.
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:
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. If these are present, they offer a handy way to characterise the shock state (eg. the high cardiac output and low peripheral resistance of sepsis).
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 is in a state of [septic, cardiogenic, distributive etc] shock."
"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 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]"
”Mr Bloggs is in a shock state, the cause of which I have thus far been unable to ascertain. This shock state is characterised by the following features: [list features, eg. warm/cool, hyperdynamic circulation, etc]"
"I note that this shock state is complicated by 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]"
"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]"
"In the meantime, my management would consist of the following supportive strategies: [outline approach to haemodynamic support and management]"