MKSAP Questions

Intern Report

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 son’s 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?

A. Adhesive capsulitis

B. Bicipital tendonitis

C. Glenohumeral arthritis

D. Rotator cuff tear

E. Rotator cuff tendonitis

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

Approach to the Hypotensive Patient

Etiologies of Shock

Hypovolemic

Cardiogenic

Distributive

Obstructive

Combined

“A significant reduction in tissue perfusion, Resulting in poor oxygen delivery to these tissues”

SHOCK Physiology

Physiologic Variable

Clinical

Preload

PCWP

Contractility

CI/CO

Afterload

SVR

Tissue Perfusion

MV02

Hypovolemic

Distributive

Cardiogenic

Obstructive

COMBINED SHOCK PROBABLY MOST COMMON

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))

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?

Initial Evaluation-History

History: rarely useful in the acute settingFood/medicine allergiesMedication changes Immunosupressed statesHypercoagulable conditionsPrexisting illnessesRecent procedures

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

While your neurons are firing…

Get appropriate IV accessLarge bore IV vs. Central access

Crash cart close by with:Levophed (Norepinephrine)DopamineVasopressinAtropineAmiodarone/BB

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

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 (PR=200msec), no ST/TW∆esBeta blocker held, receives ASA/LovenoxHD # 1, nurse calls you with BP of 68/44

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

COMPLETE HEART BLOCK

What is the diagnosis?

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

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.

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

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

SEPSIS/SIRS

WHAT IS THE LIKELY DIAGNOSIS?

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

Which Antibiotics?

Broaden coverage to include Pseudomonas, MRSACTX:Cefepime :: GNB:GNB+PsUnasyn:Zosyn :: GP/An/GN:GP/An/GN + PsSo…start with Vanc and Cefepime

(Vancopime)

Transfer to MICU

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 >30% Addition of inotropic support (dobutamine)

Read Early goal directed therapy or Sepsis guidelinesPrior to MICU

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 weekNo infectious precipitant identifiedYou go the ER to see him and you note

that his BP is 65/40, HR 115He is mentating well though

Evaluation

Exam c/w dry mucous membranes, decreased skin turgor

Repeat BP shows the same value

What should you do?

Fluids….fluids…fluids..

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

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 HD#4, nurse calls stating: “BP is 80/55, and she is complaining of chest pain

and her breathing has become more labored”

Based on this…

What is the most likely diagnosis?

Pulmonary Embolism

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

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

Case #5

P.W. 52 y/o AAF with pmh of ICM here with dyspnea and presumed HF exacerbation.

Called for “altered mental status” HD#2

BP 106/74, HR 120, RR 30

Pt lethargic on exam

What do you want to look for?

Case #5

ExamCool, dry extremitiesSinus tach500ml in last 24hrs—depsite IV lasix

LabsAST/ALT 800/900Lactate 3.0Cr up to 3.0

Based on this…

What is the most likely diagnosis?

Cardiogenic Shock

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

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

Summary Points: Hypotension

Assess patient’s mental status/rapidity of onset

Is it one of these:CardiogenicDistributive HypovolumicObstructive

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 – 5A’sArterial SupportAntibioticsAntithromboticsAnticoagulantsAdrenal Support

Do you need other studies urgently:EchoCT Abd/Chest