The objective is to assess the patient, and answer certain questions:
Previous hot cases with this sort of theme to them can be found below.
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 also ask to look at the pressure-volume loops.
It would be nice to ask what the urine output has been over the last 24 hours.
The urine may be coming out of a nephrostomy tube, or there may be a bladder irrigation set.
There may be surgical drains (what is in them? How much of it?).
An abdominal catastrophe may be the cause of renal failure.
A CVVHDF or SLEDD process may be in progress.
The savvy candidate may wish to ask the following questions:
It would be good to note exactly what is in the dialysate bags.
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.
Furthermore, the IABP- if the balloon is too low - may actually be responsible for the renal failure. One should make a mental note of this for the presentation.
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.
Specifically in renal failure, one should take notice the following drugs:
One should observe the following features of an EVD:
A MARS system or plasmapheresis apparatus may be in the room.
The latter is more likely, and might give the candidate the impression that some sort of autoimmune catastrophe has wiped out the kidneys.
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:
Clubbing Leukonychia
Nail lines:
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Onycholysis Koilonychia Splinter haemorrhages Nicotine stains Vertical nail ridges Horisontal nail ridges |
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.
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.
Palpate the arms:
One should then palpate the axillary lymph nodes.
Palpate the neck:
The renal failure patient's cranial nerve examination may be irrelevant.
In the unconscious patient, one might wish to limit oneself to the examination of the pupillary light reflex.
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 airway is also of peripheral interest in the examination of the renal failure patient.
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.
The purpose of doing the gag reflex in a renal failure hot case is actualy to look at the posterior pharynx. One might discover the red raw tonsils of a streptococcal pharyngitis, which will change the tone of one's discussion of possible aetiologies.
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. A patient with severe pneumonia may develop renal failure as a consequence of sepsis. A patient with pulmonary haemorrhage and bloody tracheal aspirates may have Goodpasture's syndrome, or some other sort of vasculitis.
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.
Large pleural effusions may be present, and this adds to the fluid balance asssessment, but they would not be obvious unless the patient is well enough to sit up.
Auscultation:
One may begin by auscultating the apices anteriorly. Then, one should auscultate as posteriorly as possible. The money is in the bases. During the discussion of fluid management, one needs to be armed with the presence or absence of pulmonary oedema as one of the findings.
Cardiac failure may be a major contributor to the renal failure.
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:
The various clicks and murmurs one encounters are discussed elsewhere.
One should make a point of looking for a pericardial rub, and for pericardial effusion.
For this, one should ask to lay the patient flat.
Abdominal observation
Abdominal palpation
Abdominal percussion
Abdominal auscultation
If the abdomen is distended or there is obvious evidence of surgical invasion, one may wish to ask about the intra-abdominal pressure, or more directly about the renal perfusion pressure.
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
The endoluminal repair of an aortic aneurysm typically leaves behind an angio sheath or at least a big hole. Enquire about anything which has recently been removed from the femoral vessels.
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.
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.
If one has ample time, one can conclude the examination by performing a brief neurological exam.
Power of the muscle groups may be tested in the following sequence:
Sit the patient back up again.
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:
"Mr Bloggs' renal failure is likely caused by [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 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]"
"My approach to dialysis in this scenario would consist of the following strategies: [discuss modality, dose, anticoagulation, frequency]"
"Mr Bloggs' renal failure is likely multifactorial; at this stage I am unable to commit to a single diagnosis."
"Contributing factors may include [list of potential contributing aetiologies]."
"I have identified clinical findings which support this hypothesis: namely, [insert list of findings]."
"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]"
"My approach to dialysis in this scenario would consist of the following strategies: [discuss modality, dose, anticoagulation, frequency]"
Number of previous hot cases in this topic: 3
Unspecified hospital in Sydney |
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Royal Brisbane and Women’s Hospital |
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Unspecified hospital |
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