Case 11: Physical Exam

Case 11 Index

Vital Signs: Temperature 98°F, Blood Pressure 150/80 mmHg, Heart Rate 85 beats/min, Respiratory Rate 14 breaths/min
General Appearance: In no acute distress, thin
HEENT: Normal conjunctiva, no scleral icterus, moist mucous membranes, clear oropharynx
Lymph: No lymphadenopathy
Cardiovascular: No JVD, regular rhythmstethoscope
Pulmonary: Breath sounds normal bilaterally, faint rales at both bases, no rhonchi/wheezes
Abdominal: Soft, normal bowel sounds, no scars, non-distended
Extremities: warm and well perfused, minimal peripheral edema of lower extremities
Neurologic: Alert, oriented x 3, no focal deficits
Psychiatric: Calm, pleasant
Skin: Warm, dry, no rash

You take a look at his hemodialysis access on his right arm and see this:

What type of vascular dialysis access are you looking at (choose one!)?
Arteriovenous fistula (AVF)
An AVF is formed by anastomosing or connecting an artery to a vein. Try again!
Arteriovenous graft (AVG)
Correct! An AVG is formed by using synthetic tubing to connect an artery to a vein.
Temporary dialysis catheter
Temporary dialysis catheters are likely to be found in the neck or groin, where they reside in large veins such as the internal jugular or femoral veins. Pick again!
Tunneled dialysis catheter
Tunneled dialysis catheters are most often found on the chest wall, where they rest in the internal jugular vein.
Now that you’ve identified the type of vascular access, what do you want to do next?
Begin the hemodialysis treatment using dialysate concentrations and flow rates from the patient’s dialysis records. Bandage the access with a sterile gauze after the treatment is finished.
We might put the patient at risk by starting the dialysis treatment through this dialysis access. Try again!
Send the patient to the emergency department immediately and inform your vascular surgery colleagues that he is on the way.
Correct! We see an exposed arteriovenous graft in the image above – a surgical emergency that requires urgent referral to the hospital and evaluation.
Tell the patient you can’t use his vascular access and cover it in a sterile gauze.  You check the patient’s labs in the dialysis unit and find no urgent indication for dialysis now. Schedule repeat labs and an urgent vascular surgery appointment for the patient on Monday. Advise the patient to limit his fluid and potassium intake and to exercise caution with his right arm.
Though we cannot use his vascular access, it would not be safe to send this patient home and schedule an appointment for Monday. Pick again!
Perform a bedside doppler ultrasound of the dialysis access and then schedule the patient for a fistulagram on Monday.
A doppler ultrasound is unlikely to help us here, and this plan may put the the patient in danger. Choose again!

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