Critical Care Self- Assessment - the Association of Physician

Critical Care SelfAssessment
Ryan O’Gowan, PA-C, MBA, FCCM, FAPACVS
Question 1
A 62 year old female with a PMH of Etoh abuse and metabolic
syndrome presents with a two day history of mid epigastric
pain which has developed over the weekend. What is the
most probable differential diagnosis at this point?
A.
B.
C.
D.
GERD
Cholecystitis
Pancreatitis
CAD
Answer
C. Pancreatitis
Discussion
The most probable diagnosis at this point is Pancreatitis, given
the history of alcohol abuse. Although GERD and Cholecystitis
are important elements of the differential and the
symptomatology of midepigastric pain. Additionally, metabolic
syndrome is a risk for diabetes mellitus, which in conjunction
with alcoholism is a risk factor for chronic pancreatitis. There is
insufficient information at present to substantiate CAD as the
most probable differential diagnosis, although it remains the
most life threatening. Cholecystitis generally presents with right
upper quadrant pain, as opposed to mid-epigastric pain.
Ref: Uptodate.com- Freedman, S et. Al. Clinical Manifestations
and diagnosis of chronic pancreatitis in adults.
Question 2
While in the office, she complains of more acute epigastric
pain-9/10, which now begins to radiate to her shoulder blade.
She last ate 18 hours ago. You transfer her to the ED. What lab
studies do you recommend upon admit to the ED, and what
other tests would be most useful as adjuncts?
A.
B.
C.
D.
LFTs, CBC, Basic Metabolic Profile, ESR, CRP, A1C.
Chest X-ray.
12 Lead EKG, CK-MB, Troponin.
PT, PTT, Fibrinogen.
Answer
C. 12 Lead EKG, CK-MB, Troponin.
Discussion
In this instance the most useful tests include a 12 lead EKG, CKMB, and Troponin, given the new radiation to the scapula. This
clinical change in the patient presentation now appears to be
more consistent with likely Left Main coronary disease.
Although the other tests are useful in assisting with qualifying
the diagnosis of pancreatitis, CAD is the most life threatening
diagnosis.
Ref: Uptodate.com-Meisel, J. Diagnostic Approach to Chest Pain
in adults.
Question 3
With your patient, the ECG shows Left Main CAD. The patient
begins to develop more pressure, which gives way to overt
chest pain. The patient is taken to the cath lab. Which of the
following is most true regarding stenting of the Left Main?
A. Most optimal outcomes are with LM disease <50%.
B. LM Stenting is superior to surgical revascularization.
C. The LeMans and SYNTAX trials included the use of bare
metal stents.
D. The AHA recommends Left Main stenting as a part of usual
care.
Answer
A. Most optimal outcomes are with LM disease <50%.
Discussion
The correct answer is A. With regards to left main stenting, the
most optimal non-surgical outcomes occur with left main
stenosis of <50%. At present, Left Main stenting outcomes are
not superior to surgical revascularization, and are not
recommended by the AHA as a part of usual care. The LeMans
and SYNTAX trials were smaller, observational trials which
included the use of drug eluting stents in the treatment of left
main disease.
Ref: Uptodate.com- Cutlip, D. Management of patients with left
main coronary disease.
Question 4
In addition, a new systolic murmur is detected and the patient’s
chest pain becomes refractory to nitroglycerin. The next angio
view shows the following:
What is your differential diagnosis now?
A. Tricuspid regurgitation
B. Post MI Ventricular Septal Defect
C. Mitral Regurgitation
D. Aortic Regurgitation
Answer
C. Mitral Regurgitation
Discussion
The correct answer is C. This ventriculogram shows mitral
regurgitation from a flail leaflet, which is secondary to a
ruptured chordae tendinae. Although tricuspid regurgitation is
also a systolic murmur, panels A and B of the above angio view
demonstrate mitral regurgitation. Post Myocardial Infarction
Ventricular septal defects may present in a similar fashion, but
may also do so later in the course of evolution of an acute MI.
The murmur of aortic regurgitation is diastolic in nature.
Ref: Uptodate.com-Latham, R. Intraaortic balloon counter
pulsation.
Question 5
An IABP is placed in the catheterization lab after the patient is
diagnosed with a flail chordae and acute mitral regurgitation.
Which of the following are not indications for Intra-Aortic
Balloon placement?
A. Critical Aortic Stenosis with ACS
B. Severe Pulmonary Hypertension
C. Critical Left Main Coronary Disease
D. Acute Mitral Regurgitation secondary to flail chordae
Answer
B. Severe Pulmonary Hypertension
Discussion
The correct answer is B. The indications for IABP placement
include chest pain refractory to medical therapy, critical left
main CAD, acute mitral regurgitation, and acute VSD.
Contraindications to IABP placement include aortic dissection
and aortic regurgitation, as these may be exacerbated by
counter pulsation.
Ref: Uptodate.com-Latham, R. Intraaortic balloon counter
pulsation
Question 6
The patient is taken to the OR 48 hours later where a
MVR/CABG x 4 is performed.
She recovers uneventfully, mends her ways, and heads home
after a week. What are key points in her follow up?
A. Anticoagulation with Warfarin for her mitral repair for a
minimum of 12 weeks.
B. Afterload reduction with an ACEI/ARB.
C. Beta Blockade, a statin, and low dose ASA.
D. All of the above.
Answer
D. All of the above.
Discussion
For patients with ischemic heart disease who are status post
MVR/CABG, this warrants anticoagulation with warfarin for a
minimum of 12 weeks, after load reduction with an ACEI/ARB,
beta blockade, a statin, and low dose baby aspirin.
Ref: Bojar, R. Manual of Perioperative Care in the Adult Cardiac
Surgery Patient, 5th Ed..
Question 7
A 68 year old male presents with a one week history of
erythema, tenderness, and warmth of his right lower extremity.
Recent exposures include an insect bite while working outside
at his brother’s family farm in Colorado. He lives with him for
part of the year. For his initial evaluation, which of the following
is least appropriate?
A.
B.
C.
D.
Tick borne illness: CRP, ESR.
Cellulitis:CBC
Necrotizing Fasciitis: CPK, U/A for hemoglobin, BUN/Cr.
Deep Vein Thrombosis: Homan's testing
Answer
D. Deep Vein Thrombosis: Homan's testing
Discussion
The answer is D. Homan’s test is neither sensitive nor specific for deep
venous thrombosis. Additionally, although frequently medical texts
may mention examining a patient for a palpable cord, other diagnoses
such as a Baker’s cyst may be a mimic. The appropriate initial
evaluation for DVT is duplex ultrasound of the extremity. D-Dimer is
noted for its high negative predictive value to exclude DVT/PE,
meaning a clinician should order this in the event that they think a DVT
or PE is not present, so as to exclude the diagnosis from their initial list
of differentials. For tick borne illnesses such as rickettsia or Lyme, CRP
and ESR may be an initial first step. Accordingly, CBC is reasonable in
evaluating cellulitis. Lastly, appropriate testing for Necrotizing fasciitis
is CPK, Bun/Cr to establish any renal dysfunction associated either with
dehydration or rhabdomyolysis, and a U/A for hemoglobin. In the
event that a urine myoglobin is not available, the U/A with + heme and
an absence of RBCs is an indicator of rhabdomyolysis.
Ref: Uptodate.com-Bauer,K. Approach to the diagnosis and
management of lower extremity deep venous thrombosis.
Question 8
On further evaluation of your patient you discover that there is a
50 pack year smoking history. Vital signs are Vitals are: HR 109,
BP 142/58, RR 19, O2 sat 88% on NRB.
Physical exam reveals some decreased breath sounds and distal
wheezing.
Baseline ABG shows pH 7.26, PCO2 68, and PaO2 55. Bicarb is 31.
What is the acid base disorder?
A.
B.
C.
D.
Acute Respiratory Acidosis
Chronic Respiratory Acidosis
Metabolic Alkalosis
Metabolic Acidosis
Answer
B. Chronic Respiratory Acidosis
Discussion
The correct answer is B, chronic respiratory acidosis. There is a
mixed disorder present with a compensatory metabolic alkalosis.
Ref: Uptodate.com-Emmet, M. Simple and Mixed Acid Base
disorders.
Discussion
The correct answer is B, chronic respiratory acidosis. There is a
mixed disorder present with a compensatory metabolic alkalosis.
Ref: Uptodate.com-Emmet, M. Simple and Mixed Acid Base
disorders.
Question 9
What physiologic effect will increased CO2 have on the
pulmonary vascular tree?
A.
B.
C.
D.
Vasodilatation of the pulmonary vascular tree
Decreased RV after load
Reduction in pre-existing tricuspid regurgitation
Vasoconstriction and hypoxia
Answer
D. Vasoconstriction and hypoxia
Discussion
The correct answer is D, vasoconstriction with resulting hypoxia.
Acute elevations in CO2 without appropriate compensation, may
precipitate RV strain and pulmonary hypertension, which in turn
increases RV after load and may therefore worsen any preexisting tricuspid regurgitation.
Ref: Uptodate.com-Feller-Kopman, D. Mechanisms, Causes, and
Effects of Hypercapnia.
Question 10
Which of the following drugs may reduce preload?
A. ACEI/ARBs
B. Phosphodiesterase Inhibitors & Nitrates
C. Opiates
D. Calcium Channel Blockers
Answer
C. Opiates
Discussion
The correct answer is C, Opiates. The other choices, ACEI/ARBs,
Calcium Channel Blockers, will reduce after load. The answer B is
a distractor as although Nitrates preload, Phosphodiesterase
Inhibitors like Milrinone may reduce both preload and after load.
Ref: Colucci, W. Inotropic Agents in Heart Failure due to Systolic
Dysfunction.
Question 11
Which of the following should be included in the differential
diagnosis of post operative ileus?
A.
B.
C.
D.
Acute GI Bleed and perforation.
Pancreatitis.
Medication interaction or side effect.
All of the above.
Answer
D. All of the above.
Discussion
Ref: Uptodate.com-Kallf,J. Post operative Ileus.
Question 12
Which of the following agents may best treat her postoperative
ileus?
A.
B.
C.
D.
Colace/Miralax.
Reglan.
Physostigmine.
µ receptor antagonists.
Answer
C. Physostigmine.
Discussion
Ref: Uptodate.com-Camilleri, M. Acute Colonic Pseudoobstruction (Ogilvie’s syndrome).