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