Internal Medicine
Certification Exam Review

Educational Objective:

Appreciate the physical examination manifestations in patients with an atrial septal defect.

Key Point:

Patients with an atrial septal defect may have a midsystolic ejection murmur and fixed split of the S2, which is evidence of pulmonary hypertension on the physical examination.

Explanation:

The most likely cause is atrial septal defect. This type of defect is the most common congenital heart disease (CHD) occurring in adults, as well as teenagers, accounting for up to 15% of all adult cases of CHD.

Patients with atrial septal defects usually have a fixed split of S2 and a midsystolic ejection murmur caused by increased flow across the pulmonic valve. Such a patient could develop pulmonary hypertension. A right ventricular fourth heart sound may be heard, which is a midsystolic ejection click and a midsystolic pulmonic murmur. Precordial bulge can be seen in patients with prominent left to right shunting. The incidence rate is higher in females; combined with common ostium secundum defects, the female-to-male ratio is 2:1.

References:

Gandhi A. Atrial septal defect. Last reviewed January 26, 2015. Accessed April 5, 2017.

Krasuski RA. Congenital heart disease in the adult. Published August 2010. Accessed April 5, 2017.

Perloff JK. Clinical assessment. In: Gatzoulis MA, et al, eds. Diagnosis and Management of Adult Congenital Heart Disease. 2nd ed., 2011.

Educational Objective:

Review the vasopressors available for patients in septic shock and their benefits and risks.

Key Point:

Norepinephrine is the preferred initial vasopressor in a patient with septic shock whose condition has failed fluid resuscitation.

Explanation:

Norepinephrine is the first choice of vasopressor for the treatment of sepsis. Epinephrine can be added as a second agent when needed to maintain blood pressure. Dopamine is recommended only in patients with a low risk of tachyarrhythmia and who have bradycardia. It was shown in a trial to have no benefit over norepinephrine and a small increase in the risk of death/serious AEs was seen. It has not been shown to have any renal protection effects at low doses, as was previously thought. Phenylephrine is a selective alpha-1 agonist that will increase systemic vascular resistance without changing cardiac output. It can produce reflex bradycardia, not tachycardia. It is recommended only in rare cases as salvage therapy.

References:

Dellinger P, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;4(2):580-620.

Rivers E. Approach to the patient with shock (chapter 106). In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2015:672-681.e2.

Educational Objective:

Know when to transfuse in anemic patients who have chronic liver disease.

Key Point:

Over transfusion of patients with portal hypertension can raise portal pressures enough to exacerbate bleeding.

Explanation:

A hemoglobin value of 7 g/dL should trigger transfusion of PRBCs in this patient.

It is particularly important that patients with portal hypertension/variceal bleeding not be overtransfused, because overtransfusion can raise portal pressures and exacerbate bleeding.

A large study of patients with upper gastrointestinal bleeding showed improved outcomes using a conservative transfusion strategy with PRBC transfusion only for hemoglobin levels lower than 7 g/dL. This recommendation may be too conservative for patients with severe cardiovascular disease or among those who are profoundly hypovolemic. Vital signs taken in the supine, sitting, and standing positions can be very helpful in identifying such patients.

References:

Kovacs TO, Jensen DM. Gastrointestinal hemorrhage. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016: 879-884.

Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11-21.

Educational Objective:

Use plain radiography in diagnosing axial spondyloarthritis.

Key Point:

Axial spondyloarthritis causes chronic back pain that improves with exercise and enthesitis in young patients. A plain x-ray may confirm the diagnosis.

Explanation:

The patient has axial spondylarthritis (formerly known as ankylosing spondylitis), a chronic inflammatory disease characterized by the presence of chronic back pain that usually improves with exercise but not with rest. Limitation in the range of motion on physical exam may be apparent. In addition, this patient has enthesitis, which is inflammation in the region of attachment of the Achilles tendon (or any other tendon as a matter fact). A plain x-ray of the pelvis should be obtained. This may reveal erosions, ankylosis or sclerosis. If the x-ray is noncontributory an MRI of the sacroiliac joints may provide additional details.

HLA-B27 is very common in patients with axial spondyloarthritis and a positive finding confirms the diagnosis, however the test may not be readily available and is not indicated if other strong diagnostic evidence is present. An MRI of the Achilles tendon will not help clarifying the diagnosis. Occasionally ankylosing spondylitis is associated with inflammatory bowel disease and in those cases the anti-Saccharomyces antibody may be positive, however there is no history of gastrointestinal complaints in this patient.

References:

Ledford C. Spine Conditions: Mechanical and Inflammatory Low Back Pain. FP Essent. 2017 Oct;461:15-20.

Terenzi R, Monti S, Tesei G, Carli L. One year in review 2017: spondyloarthritis. Clin Exp Rheumatol. 2018 Jan-Feb;36(1):1-14.

Educational Objective:

Treat septic bursitis in an immunocompromised patient.

Key Point:

Oral antibiotics are insufficient therapy for septic bursitis in an immunocompromised patient.

Explanation:

This is an elderly immunocompromised patient with septic olecranon bursitis. Extended leaning on the elbows may be a predisposing factor, as this is often seen in patients with COPD.

He also has signs of sepsis that warrant hospitalization to initiate intravenous antimicrobials. Intravenous nafcillin, oxacillin, and cefazolin are appropriate initial choices. If methicillin-resistant S aureus is suspected, then vancomycin, linezolid, or daptomycin should be used.

Oral cephalexin and clindamycin are not appropriate treatment choices. The most common pathogen is Staphylococcus. In septic bursitis, Pseudomonas is rarely the causative bacteria. The duration of treatment is based on the patient’s response to therapy. It may require several weeks of antibiotic therapy and repeated aspirations.

Reference:

Matteson EL, Osmon DR. Infections of bursae, joints, and bones (chapter 272). In: Goldman L, Schafer A. Goldman-Cecil Medicine. 25th ed., 2016:1805-1810.