MKSAP Questions

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MKSAP Questions

• Intern Report

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General Internal Medicine Question 72

• A 47 y/o man is evaluated for right lateral
  shoulder pain. He has been pitching during
  batting practice for his sons little league
  baseball team for the past 2 months. He has
  shoulder pain when lifting his arm overhead and
  also when lying on the shoulder while sleeping.
  Acetaminophen has not been helpful. On physical
  exam, he has no shoulder deformities or swelling.
  Range of motion is normal. He has subacromial
  tenderness to palpation, with shoulder pain
  elicited at 60 degrees of passive abduction. He
  also has pain with resisted midarc abduction but
  no pain with resisted elbow flexion or forearm
  supination. He is able to smoothly lower his
  right arm from a fully abducted position, and his
  arm strength for abduction and external rotation
  against resistance is normal.
• Which of the following is the most likely
  diagnosis in this patient?
• Adhesive capsulitis
• Bicipital tendonitis
• Glenohumeral arthritis
• Rotator cuff tear
• Rotator cuff tendonitis

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General Internal Medicine Question 72

• E. Rotator cuff tendonitis
• inflammation of the supraspinatus and/or
  infraspinatus tendon that can also involve the
  subacromial bursa, common overuse injury
• subacromial tenderness and impingement
• Pain occurs with overhead reaching and when lying
  on the side
• The passive painful-arc maneuver assesses the
  degree of impingement
• Pain with resisted midarc abduction is a specific
  finding for rotator cuff tendonitis
• Appropriate treatments include NSAIDs, ice, and
  exercise
• Adhesive capsulitis (frozen shoulder) decreased
  range of shoulder motion resulting from stiffness
  rather than from pain or weakness
• Bicipital tendonitis overuse injury, tender
  bicipital groove, and anterior shoulder pain is
  elicited with resisted forearm supination or
  elbow flexion
• Glenohumeral arthritis related to trauma and the
  gradual onset of pain and stiffness over months
• Torn rotator cuff arm weakness, particularly
  with abduction and/or external rotation
• A positive drop-arm test is a very specific but
  relatively insensitive method for diagnosing
  rotator cuff tear

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Approach to the Hypotensive Patient
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Etiologies of Shock

• Hypovolemic
• Cardiogenic
• Distributive
• Obstructive
• Combined

A significant reduction in tissue perfusion,
Resulting in poor oxygen delivery to these
tissues
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SHOCK Physiology
Physiologic Variable Clinical Preload PCWP Contractility CI/CO Afterload SVR Tissue Perfusion MV02
Hypovolemic ? ? ? ?
Distributive ?? ? ? ?
Cardiogenic ? ? ? ?
Obstructive ?? ?? ? ?
COMBINED SHOCK PROBABLY MOST COMMON
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SHOCK Management-Basics

• Increase preload
• Increase contractility
• Increase/decrease afterload
• Increase oxygen delivery

Oxygen Delivery CO X ((1.34 x hemoglobin
concentration x SaO2) (0.0031 x PaO2))
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Initial Evaluation

• What are the vital signs?
• Check BP in both arms
• Is the patient mentating well or confused?
• What has their urine output been?
• What is the BP trend?
• Reason for admission?
• Do they have IV access?
• Does the patient look well?

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Initial Evaluation-History

• History rarely useful in the acute setting
• Food/medicine allergies
• Medication changes
• Immunosupressed states
• Hypercoagulable conditions
• Prexisting illnesses
• Recent procedures

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Initial Evaluation - Physical Exam

• Evidence of
• Intravascular volume depletion
• Obstructive symptoms (RV heave, pulsus paradox)
• Irregular rhythm, murmurs, rubs, gallops
• Peritoneal signs, ascites
• Peripheral vasodilation (hyperemic skin)
• Peripheral vasoconstriction (cold, clammy skin)
• Decreased breath sounds

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While your neurons are firing

• Get appropriate IV access
• Large bore IV vs. Central access
• Crash cart close by with
• Levophed (Norepinephrine)
• Dopamine
• Vasopressin
• Atropine
• Amiodarone/BB

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How do we investigate this?

• All must be sent STAT
• CBC, Coag panel - evidence of blood loss
• BMP - evidence of lactic acidosis from tissue
  hypoperfusion
• Troponins
• ECG
• Echo - evidence of pump failure, RV dysfunction,
  pericardial tamponade

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Case 1

• JB is a 75 y.o WM with hx of CAD, DM2, HTN
  admitted for chest pain/ischemic evaluation
• Initial ECG shows sinus bradycardia with 1st deg
  AVB (PR200msec), no ST/TW?es
• Beta blocker held, receives ASA/Lovenox
• HD 1, nurse calls you with BP of 68/44

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This is not what I signed up for!!

• Patient is oriented but lethargic
• Repeat BP is 65/42, HR 45 bpm
• Exam no JVD, intravasc vol. depletion,
  obstructive sx
• IVF NS wide-open
• Tele Review sinus pauses 4 sec

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(No Transcript)
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Complete heart block

• What is the diagnosis?

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To Pace Or Not..

• Atropine 1 mg IV given
• HR increased to 65, BP increased to 85/55
• Place TLC catheter
• Pacing pads applied
• Transcutaneous pacing at 65 bpm
• Transfer to CCU
• Dopamine

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Complete Heart Block - Summary

• Assess hemodynamics
• Look at escape rhythm
• Width of the QRS complex predicts location in AV
  node and response to atropine
• Narrow higher location, better response to
  atropine
• Evaluate for ischemia-usually vagal mediated
• Anterior MI
• Inferior MI
• Are there any reversible etiologies such as
  medications, electrolytes, etc.

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Case 2

• A.B is a 67 y.o AAM with hx of CKD, CHF, HTN,
  COPD admitted for cough, fevers
• CXR c/w LL PNA, initials vitals stable
• Treated with Rocephin Azithro
• Sputum/blood cx pending
• On HD 3, while on rounds, you notice patient to
  be somnolent and confused

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Should I run away now?

• STAT Vitals
• BP 85/50. HR 115. O2 sat 89 RA
• Review of previous vitals show BP decreasing
  gradually during past 12 hours
• Fever up to 103.1 F o/n
• Exam c/w decrease BS at R base, warm hyperemic
  peripheral extremities
• ECG Sinus tachy. No ST/TW changes

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SEPSIS/SIRS

• WHAT IS THE LIKELY DIAGNOSIS?

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Management

• IVF NS (wide-open) with TLC in place
• Repeat BP in 10 min
• BP 75/60 after 1 liter NS, more lethargic
• Start pressors
• Levophed (Norepinephrine) - increase SVR
• Let nursing staff know of likely ICU transfer
• Repeat BP on pressors
• BP 90/55, 85/55, 93/60
• Send blood and urine cultures
• Send STAT labs including ABG, CBC, BMP, coag
  panel

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Which Antibiotics?

• Broaden coverage to include Pseudomonas, MRSA
• CTXCefepime GNBGNBPs
• UnasynZosyn GP/An/GNGP/An/GN Ps
• Sostart with Vanc and Cefepime (Vancopime)
• Transfer to MICU

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Sepsis Protocol

• Applicable to ICU patients
• Goal directed resuscitation
• IVF guided by CVP at least up to 10 mmHg
• Assess MAP 65 mmHg
• Pressor support usually levophed
• Vasopressin useful in profound acidemia
• Avoid dopamine in excessive tachy states
• Assess perfusion Mixed Venous SV02 (70)
• Transfusion of pRBCS to Hct gt30
• Addition of inotropic support (dobutamine)

Read Early goal directed therapy or Sepsis
guidelines Prior to MICU
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Case 3

• J.R. is a 45 y.o. WM with hx of Crohns, being
  treated with TNF-? therapy, and prednisone
• Admitted for increased N/V/D for 1 week
• No infectious precipitant identified
• You go the ER to see him and you note that his BP
  is 65/40, HR 115
• He is mentating well though

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Evaluation

• Exam c/w dry mucous membranes, decreased skin
  turgor
• Repeat BP shows the same value
• What should you do?

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Fluids.fluidsfluids..

• IVF NS Aggressive rescucitation
• Pan-culture (risk of infection is high 2/2
  concurrent immunosuprressive therapy)
• Ask about history of glucocorticoid tx
• Check for adrenal insufficiency
• Dosing stress-dose steroids
• Hydrocortisone 100 mg IV q6h OR
• Dexamethasone 4 mg IV q6h does not affect
  cortisol assay

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Case 4

• D.F is a 54 y.o. WF with history of scleroderma,
  and secondary pulmonary hypertension, admitted
  for worsening ascites
• Being treated with diuretics and antibiotics for
  SBP
• On HD4, nurse calls stating
• BP is 80/55, and she is complaining of chest
  pain and her breathing has become more labored

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Based on this

• What is the most likely diagnosis?
• Pulmonary Embolism

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What next?

• Vitals are same on repeat
• Exam c/w incr JVP, RV heave, mild facial plethora
• IVF/Access established
• Heparin gtt initiated for suspecting PE
• Repeat BP in 10 minutes - still 80/50

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Transfer To ICU

• Is it ever too much fluid during resuscitation?
• Concept of LV/RV interdependence
• Pressor support
• Which one?
• Levophed preferred - less likely to cause tachy
• Dopamine - easily available
• Dobutamine NOT A PRESSOR
• Can consider using thrombolytics in this case for
  refractory
• Hypoxemia
• Hypotension

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Case 5

• P.W. 52 y/o AAF with pmh of ICM here with dyspnea
  and presumed HF exacerbation.
• Called for altered mental status HD2
• BP 106/74, HR 120, RR 30
• Pt lethargic on exam

What do you want to look for?
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Case 5

• Exam
• Cool, dry extremities
• Sinus tach
• 500ml in last 24hrsdepsite IV lasix
• Labs
• AST/ALT 800/900
• Lactate 3.0
• Cr up to 3.0

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Based on this

• What is the most likely diagnosis?
• Cardiogenic Shock

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Now what.

• IV access, airway, crash cart and oxygen.
• Assess for ischemia
• Dobutamine 2.5mcg
• CCU and PA catheter
• Calcium IV if hypocalcemic
• Pressors if need be

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Cardiogenic Shock

• SHOCK MI
• Early, open artery
• Assess for end organ perfusion
• BP not good enough
• Mechanical Support
• IABP, Tandem heart, impella, LVAD
• Mortality is high
• 50-80 in hospital mortality

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Summary Points Hypotension

• Assess patients mental status/rapidity of onset
• Is it one of these
• Cardiogenic
• Distributive
• Hypovolumic
• Obstructive
• Make sure you have adequate access
• Make sure you have recent labs checked
• Keep a close eye on their respiratory status

• Are you covering your bases 5As
• Arterial Support
• Antibiotics
• Antithrombotics
• Anticoagulants
• Adrenal Support
• Do you need other studies urgently
• Echo
• CT Abd/Chest