Surgery EOR 2 PDF

Surgery EOR GI/Nutritional 50% Abdominal RUQ LUQ Epigastric Lower Abdominal Pain Pain Biliary Colic...

Surgery EOR GI/Nutritional 50% Abdominal RUQ LUQ Epigastric Lower Abdominal Pain Pain Biliary Colic Splenomegaly Acute Myocardial Infarction Appendicitis intense, dull discomfort located in the RUQ or pain or discomfort in LUQ, left shoulder pain, &/or may be associated w/ SOB & exertional sxs periumbilical pain initially that radiates to the epigastrium early satiety RLQ associated w/ N/V, & diaphoresis Acute Pancreatitis associated w/ anorexia, N/V generally lasts at least 30min, plateauing within 1hr Splenic Infarct acute onset, persistent upper abdominal pain Diverticulitis Acute Cholecystitis severe LUQ pain radiating to the back generally LLQ pain, usually constant & present prolonged (>4-6hrs) RUQ or epigastric pain, fever for several days prior to presentation pts will have abdominal guarding & Murphy’s sign Splenic Abscess Chronic Pancreatitis may have associated N/V Acute Cholangitis associated w/ fever & LUQ tenderness epigastric pain radiating to the back Nephrolithiasis fever, jaundice, RUQ pain pain MC symptom varies from mild to severe Sphincter of Oddi Dysfunction Splenic Rupture Peptic Ulcer Disease generally, flank pain, but may have abdominal RUQ pain is similar to other biliary pain may complain of LUQ, left chest wall, or left epigastric pain or discomfort is the most prominent or back pain Acute Hepatitis shoulder pain that is worse w/ inspiration symptom Pyelonephritis RUQ pain w/ fatigue, malaise, N/V, anorexia associated w/ dysuria, frequency, urgency, pts may also have jaundice, dark urine, & light- GERD hematuria, fever, chills, flank pain, & CVA colored stools associated w/ heartburn, regurgitation, & dysphagia tenderness Perihepatitis (Fitz-Hugh-Curtis Syndrome) Acute Urinary Retention RUQ pain w/ a pleuritis component, pain is Gastritis/Gastropathy present w/ lower abdominal pain & discomfort; sometimes referred to the right shoulder abdominal discomfort/pain, heartburn, N/V, inability to urinate Liver Abscess hematemesis Cystitis fever & abdominal pain are MC sxs associated w/ dysuria, frequency, urgency, & Budd-Chiari Syndrome Functional Dyspepsia hematuria sxs include fever, abdominal pain, abdominal the presence of one or more of the following: Infectious Colitis distention (from ascites), lower extremity edema, postprandial fullness, early satiety, epigastric pain, or diarrhea is the predominant symptom, may jaundice, GI bleeding, &/or hepatic encephalopathy burning also have associated abdominal pain, which may Portal Vein Thrombosis be severe sxs include abdominal pain, dyspepsia, or GI Gastroparesis bleeding N/V, abdominal pain, early satiety postprandial fullness, & bloating GI About Diagnostics Management Anorexia Appendicitis Lower GI Bleed Appendicitis: spiral CT, U/S (may see a large, noncompressible appendix or Depends on the cause periumbilical pain (intermittent & crampy) hematochezia (bright red blood per rectum), w/ fecalith), abdominal x-ray N/V or w/o abdominal pain, melena, anorexia, fatigue, anorexia syncope, SOB, shock Gastric Ulcer: HX/PE, EGD w/ multiple bx (looking for gastric cancer) pain migrates to RLQ (constant & intense pain), usually in 24hrs Carcinoma of the Gallbladder Duodenal Ulcer: HX/PE, EGD, UGI series (if the pt is not actively bleeding) biliary colic, weight loss, anorexia Gastric Ulcers many pts are symptomatic until late; may present Gastric Cancer: EGD w/ bx, endoscopic U/S to evaluate the level of invasion, CT of epigastric pain & vomiting, anorexia, & nausea as acute cholecystitis abdomen/pelvis for metastasis, CXR, labs Duodenal Ulcers Pancreatic Carcinoma Lower GI Bleed: HX/PE, NGT aspiration (to r/o UGI bleeding; bile or blood must be epigastric pain – burning or aching, usually painless jaundice from obstruction of the seen; otherwise, performed EGD), anoscopy/proctoscopic exam several hours after a meal (food, milk, or common biliary duct antacids initially relieve pain) weight loss, abdominal pain, back pain, weakness Carcinoma of the Gallbladder: U/S, abdominal CT, ERCP bleeding, back pain N/V, anorexia, ↓ appetite pruritis from bile salts in the skin; anorexia Courvoisier’s sign Pancreatic Cancer: abdominal CT, U/S, cholangiography (ERCP to r/o Gastric Cancer acholic stools choledocholithiasis & cell brushings), endoscopic U/S w/ bx weight loss, emesis, anorexia, pain/epigastric dark urine, diabetes discomfort, obstruction, nausea  Gallbladder About Clinical Manifestations Diagnostics Management Cholelithiasis Gallstones in the biliary tract (usually in the Most are asymptomatic – may be an incidental U/S – initial TOC: stone in GB or cystic duct Observation if asymptomatic gallbladder) w/o inflammation finding Types of Gallstones: Symptomatic: ursodeoxycholic acid may be cholesterol (MC) Biliary colic: episodic, abrupt RUQ or epigastric used to dissolve the gallstones (takes 6- black stones: hemolysis or ETOH-related cirrhosis pain, resolves slowly, lasting 30min-hrs; may be 9mo); elective cholecystectomy brown stones: ↑ in Asian population, parasitic, associated w/ nausea & precipitated by fatty bacterial infections foods or large meals Complications: choledocholithiasis, acute cholangitis, acute cholecystitis Risk Factors: 5Fs (fat, fair, female, forty, fertile) OCPs (increased estrogen), Native Americans, bile stasis, chronic hemolysis, cirrhosis, infection, rapid weight loss, IBD, TPN, fibrates, increased triglycerides Acute Cholecystitis Inflammation & infection of the gallbladder due to Continuous RUQ or epigastric pain – may be U/S – initial TOC: thickened or distended gallbladder, NPO, IV fluids, abx (ceftriaxone + obstruction of the cystic duct by gallstones precipitated by fatty foods or large meals pericholecystic fluid, sonographic Murphy’s sign metronidazole) followed by may be associated w/ nausea, guarding, anorexia cholecystectomy (usually within 72hrs; Etiologies: E. coli MC, klebsiella, other gram-neg CT scan: alternative to U/S; can detect complications laparoscopic preferred) enteric organisms PE: fever (often low-grade); enlarged, palpable Labs: ↑ WBCs (leukocytosis w/ left shift), ↑ Cholecystostomy (percutaneous drainage) Chronic Cholecystitis: gallbladder bilirubin, alk phos, & LFTs if nonoperative fibrosis & thickening of the gallbladder due to MURPHY’S SIGN: RUQ pain or inspiratory arrest chronic inflammatory cell infiltration of the w/ palpation of the gallbladder HIDA scan: most accurate test – cholecystitis present Cholesterolosis: fat deposits on GB à gallbladder evident on histopathology – almost Boas sign: referred pain to the right shoulder or if there is no visualization of the gallbladder “strawberry GB”; tx is cholecystectomy always associated w/ gallstones subscapular area (phrenic nerve irritation) Choledocholithiasis Gallstones in the common bile duct (can lead to Prolonged biliary colic: RUQ or epigastric pain, Labs: ↑ AST/ALT, alk phos, & GGT (cholestasis) ERCP stone extraction preferred over cholestasis due to blockage) N/V – pain usually more prolonged due to the laparoscopic choledocholithotomy presence of the stone blocking the bile duct U/S – initial PE: RUQ or epigastric tenderness, jaundice ERCP: dx TOC – diagnostic + therapeutic Acute Ascending biliary tract infection secondary to obstruction of Charcot’s Triad: fever + RUQ pain + jaundice Labs: IV abx Cholangitis the common bile duct – e.g., gallstones, malignancy leukocytosis piperacillin/tazobactam Reynold’s Pentad: + shock or AMS cholestasis: ↑ alk phos & GGT metronidazole + cephalosporin Etiologies: E. coli MC ↑ bilirubin > increased ALT/AST metronidazole + cipro/levofloxacin CBD decompression & stone extraction U/S – initial (ERCP) MRCP Cholangiography via ERCP: gold standard Eventually à elective cholecystectomy Primary Sclerosing Autoimmune, progressive cholestasis leading to Jaundice, pruritis, fatigue, RUQ pain, Cholestatic pattern: ↑ alk phos & GGT, ↑ AST/ALT, Stricture dilation for symptomatic relief Cholangitis diffuse fibrosis of intra/extrahepatic biliary ducts hepatomegaly, splenomegaly bilirubin, IgM Cholestyramine for pruritis Risk Factors: + P-ANCA hallmark MC associated w/ IBD – UC (90%) Liver transplant definitive men 20-40yrs MRCP, ERCP – most accurate test: beaded appearance of biliary ducts (narrowing, strictures) Complications: cirrhosis, liver failure, cholangiocarcinoma Liver bx – rarely used GI About Clinical Manifestations Diagnostics Management Acute Pancreatitis acinar cell injury à intracellular activation Epigastric pain Criteria: 2/3 “rest the pancreas” of pancreatic enzymes à autodigestion of radiates to back (1) acute onset epigastric pain radiating to back pancreas exacerbated if supine, relieved leaning forward (2) ↑ lipase/amylase ≥3xULN Supportive: (3) CT, MRI, or U/S findings of acute pancreatitis NPO Etiologies: N/V, fever *no imaging required if pt meets first 2 criteria high-volume IVF (LR preferred) gallstones (MC), ETOH abuse (2nd MC) analgesia (Meperidine) meds: thiazides, protease inhibitors, PE: Labs: exenatide, valproic acid epigastric tenderness ↑ lipase/amylase (lipase more specific) Antibiotics: others: iatrogenic (ERCP), malignancy, tachycardia ALT 3-fold ↑ à gallstone pancreatitis indicated only if >30% necrosis seen scorpion sting, trauma, CF, adynamic ileus à decreased bowel sounds hypocalcemia: necrotic fat binds calcium hypertriglyceridemia, hypercalcemia, severe à dehydration, shock leukocytosis Ranson’s Criteria: infection, mumps (children) ↑ glucose, bilirubin, triglycerides Admission: Necrotizing, hemorrhagic: (1) glucose >200mg/dL Cullen’s sign (periumbilical) Abdominal CT: dx imaging of choice (2) age >55yrs Grey Turner sign (flank) also perform in pts who fail to improve/worsen (3) LDH >350IU/L after 48hrs (4) AST >250IU/dL (5) WBC >16,000/µL Transabdominal U/S: Within 48hrs: assess for gallstones & bile duct dilation (6) calcium 10% Abdominal x-ray: (8) PO2 5mg/dL segment in LUQ (10) base deficit >4mEq/L colon cutoff sign: abrupt collapse of colon near (11) sequestration of fluid >6L pancreas Interpretation: calcification à chronic pancreatitis ≥3 à severe pancreatitis likely 1000pg/mL + gastric pH hernia > neoplasms DX: plain abdominal x-rays (supine/standing), CT w/w/o contrast goals ⇢ resection of necrotic bowel & LBO MCC: adenocarcinoma > scarring secondary to diverticulitis > volvulus dilated bowel loops w/ air-fluid levels in ladder-like appearance decompression of obstructed segment major factor in clinical course of LBO is competence of ileocecal valve ▪3-6-9 rule: small bowel >3cm, large bowel >6cm, cecum >9cm Options: ▪30% ⇢ incompetent ileocecal valve: allows decompression of large bowel into ileum ▪SBO dilated loops ⇢ central, LBO dilated loops ⇢ peripheral resection + primary anastomosis ▪MC ⇢ ileocecal valve does NOT allow reflux to occur: closed loop obstruction w/ rapidly ⇡ little/no air distal to obstruction resection + diversion, diversion alone intraluminal pressure ⇢ impaired capillary circulation, mucosal ischemia, bacterial translocation pneumoperitoneum ⇢ perforation endoscopic stent placement w/ systemic toxicity ⇢ gangrene, perforation SIGMOID Volvulus: coffee bean sign (bent inner tube, kidney bean) dilated loop w/ absent haustrae, arises in LLQ & extends ⇢ RUQ Cecal: ileocecal resection or R colectomy w/ VOLVULUS: torsion of bowel on its axis ⇢ closed loop obstruction; sigmoid MC (75%), cecal (25%) proximal colonic/small bowel dilation w/ air-fluid levels, ⊘distally ileocolic anastomosis torsion of mesenteric vascular pedicle ⇢ occlusion/thrombosis of mesenteric vessels ⇢ bowel CECAL Volvulus: Sigmoid: strangulation, ischemia, & gangrene dilated loop w/ maintained haustrae, arises in RLQ & extends ⇢ LUQ ⊘signs of peritonitis: upward displacement of appendix, ⊘colonic dilation distally sigmoidoscopy w/ rectal tube insertion for dilated small bowel loops w/ multiple air-fluid levels decompression, detorsion, & reduction CT (volvulus): whirl sign pathognomonic surgery if fails ⊕signs of peritonitis/ischemia: sigmoid colectomy & primary anastomosis GI Bariatric Indications: Prerequisite: participation in supervised Common Postoperative Concern ⇢ nutrient deficiencies ▪micronutrient supplementation recommended for all patients Surgery BMI >35 + comorbidity (e.g., HTN, diabetes) dietary program without success ▪postop screening: q3-6mo x1y, then annually following bariatric surgery BMI ≥40 +/- comorbidity Fat-Soluble Vitamins: Absorption: Highest Risk: S/SXS of Deficiency: Restrictive: limit caloric intake by ⇣ stomach’s reservoir capacity A, D, E, K ▪jejunum & ileum ▪BPD-DS > RYGB A ⇢ night blindness, xerophthalmia, keratomalacia, Sleeve Gastrectomy (SG): resection of greater curvature Bitot spot, follicular hyperkeratosis restrictive + hormonal changes 60% weight loss @2y D ⇢ Rickets, osteomalacia, craniotabes, rachitic rosary ▪less hunger, improved insulin resistance & glycemic control E ⇢ sensory/motor neuropathy, ataxia, retinal Laparoscopic Adjustable Gastric Banding (LABG): *RARELY PERFORMED degeneration, hemolytic anemia tight, adjustable prosthetic band around stomach entrance ⇢ purely restrictive K ⇢ hemorrhagic disease replaced by other procedures that offer better results for weight loss/comorbidity resolution Water-Soluble Vitamins: Absorption: Highest Risk: S/SXS of Deficiency: Malabsorptive: bypass duodenum & small intestine to limit nutrient absorption Vitamin B1 (thiamine) ▪duodenum & ▪RYGB & BPD-DS ▪Beriberi – CHF (wet beriberi), aphonia, peripheral Restrictive + Malabsorptive: combination of both mechanisms proximal jejunum neuropathy, confusion, coma Biliopancreatic Diversion w/ Duodenal Switch (BPD-DS): ▪Wernicke encephalopathy (nystagmus, ataxia, use limited by high rates of malnutrition, anemia, diarrhea, & stomal ulceration ophthalmoplegia) Single-Anastomosis Duodenoileal Bypass w/ Sleeve Gastrectomy (SADI-S): Vitamin B12 ▪gastric acid cleaves ▪RYGB ▪megaloblastic anemia (pernicious anemia) ▪restrictive + malabsorptive + hormonal mechanisms ▪85% weight loss @2y B12 into its free form for absorption ▪peripheral neuropathy w/ impaired proprioception ▪primary bariatric procedure; also used as conversional procedure for inadequate weight loss ▪may include axonal or optic neuropathy & slowed after RYGB or SG mentation Roux-en-Y Gastric Bypass (RYGB): Folate ▪small intestine ▪BPD ▪megaloblastic anemia, may include sensory ▪small stomach pouch created & connected directly to small intestine ▪70% weight loss @2y *less common w/ RYGB/SG predominant neuropathy ▪restrictive + malabsorptive + hormonal mechanisms ▪Dumping Syndrome: nausea, weakness, sweating, faintness, & possibly diarrhea soon after Vitamin C (ascorbic acid) ▪scurvy ⇢ fatigue, petechiae, ecchymosis, bleeding eating within first few years after surgery ⇢ symptoms intensify w/ high-sugar foods *uncommon as long as patient consumes fruits & vegetables gums, depression, dry skin, impaired wound healing One-Anastomosis Gastric Bypass (OAGB): “mini-gastric bypass” Trace Minerals: Absorption: Highest Risk: S/SXS of Deficiency: ▪narrow stomach pouch made from lesser curvature & connected to small intestine Iron *one of the ▪duodenum & ▪RYGB, BPD-DS, SG* ▪anemia, pica, impaired learning ▪weight loss outcomes comparable to RYGB MC deficiencies proximal jejunum *requires cleavage by gastric acid in stomach, SG ⇣ stomach size restrictive + malabsorptive, probably hormonal after bariatric surgery Zinc ▪duodenum & ▪BPD-DS > RYGB > LAGB ▪growth retardation, delayed sexual maturity, impaired proximal jejunum immune function, impotence Other: Calcium ▪duodenum & ▪BPD-DS, RYGB, SG ▪metabolic bone disease, 2° hyperparathyroidism proximal jejunum *best absorbed in acidic environment Constipation About Management Etiologies: Fiber, laxatives disordered movement of stool through colon/anus/rectum (usually proximal GI tract intact) slow colonic transport: idiopathic, motor disorders (CRC, DM, hypothyroid), adverse effects of drugs (verapamil, opioids); outlet delay: Hirschsprung’s disease Gastroparesis: condition that affects the stomach muscles & prevents proper stomach emptying MCC: diabetes; others: anorexia, bulimia, scleroderma, Ehlers-Danlos, adnominal surgery S/SX: nausea, full feeling after little food is eaten; palpitations, heartburn, bloating, decreased appetite, GERD DX: KUB, manometry, gastric emptying scan TX: low fiber & low residue diets, restrict fat intake, smaller meals spaced 2-3hrs apart; metoclopramide Ileus: ileus that persists >3d following surgery is termed postoperative adynamic ileus or paralytic ileus PATHO: hypomobility of the GI tract in the absence of mechanical bowel obstruction S/SX: absent bowel sounds DX: CT scan w/ gastrografin – must exclude mechanical obstruction TX: spontaneously resolves after 2-3d; D/C opiates PHARM About Fiber MOA: retains water & improves GI transit Bulk Forming Laxatives MOA: absorbs water & increases fecal mass; increases the frequency & softens the consistency of stool w/ minimal effects Psyllium Methylcellulose dietary fiber + bulk forming laxatives most physiologic & effective approach Polycarbophil Wheat dextran ADRs: flatulence, bloating Osmotic Laxatives Sorbitol MOA: causes water retention in stool (osmotic effect pulls water into gut) Polyethylene glycol (PEG) Lactulose ADRs: flatulence, bloating Saline Laxatives: milk of magnesia, mag citrate saline laxatives à hypomagnesemia (esp. w/ chronic renal disease) Stimulant Laxatives MOA: increases acetylcholine-regulated GI motility (peristalsis) & alters electrolyte transport in the mucosa Bisacodyl Senna ADRs: diarrhea, abdominal pain GI About Clinical Manifestations Diagnostics Management Colorectal Most arise from adenomatous polyps Iron deficiency anemia (fatigue, weakness), Colonoscopy w/ bx: diagnostic TOC Localized: surgical resection (radical vs. Cancer (CRC) MC cause of large bowel obstruction in adults rectal bleeding, abdominal pain, change in endoscopic) + post-op chemo to destroy bowel habits Barium enema: apple core lesion residual cells & micrometastases Risk Factors: age >50yrs (peak 65yrs), AA, family hx of CRC Advanced disease: ascites, abdominal masses, Labs: iron deficiency anemia, (CRC is MC cause of occult Metastatic: palliative chemo IBD: UC > Crohn hepatomegaly GI bleeding in adults) diet (low fiber, high in red or processed meat, animal fat) Chemotherapy: obesity, smoking, ETOH Right-Sided (Proximal): chronic occult Tumor markers: CEA is MC monitored FOLFOX bleeding (iron deficiency anemia, + guaiac), -folinic acid (leucovorin calcium) Protective Factors: physical activity, regular use of ASA, NSAIDs diarrhea Screening: any of the 3 approaches -fluorouracil fecal occult blood test annually starting at 50yrs -oxaliplatin Genetics: Left-Sided (Distal): bowel obstruction; colonoscopy q10yrs for ages 50-75 FOLFIRI Familial Adenomatous Polyposis: genetic mutation of APC present later & cause changes in stool flexible sigmoidoscopy q5yrs + fecal occult blood testing -folinic acid (leucovorin calcium) gene; adenomas begin in childhood – almost all will develop diameter – may develop Streptococcus bovis q3yrs -fluorouracil colon cancer by age 45yrs; prophylactic colectomy best for endocarditis -irinotecan survival Lynch Syndrome: colonoscopy q1-2yrs beginning at 20- VGEF inhibitor: bevacizumab ↓ risk: 25yrs Turcot Syndrome: FAP-like syndrome + CNS tumors pedunculated (medulloblastoma, glial tumors) tubular FAP: flexible sigmoidoscopy annually beginning 10-12yrs 5% procedures that include exposure to nephrotoxic substances (e.g., iodinated IV contrast) ▪major intraperitoneal, intrathoracic, or vascular surgery Fasting glucose, A1c: known diabetes + no A1c within last 3mo ▪lung/liver transplant, cystectomy LFTs: chronic liver disease, symptoms of liver disease (e.g., jaundice, hepatomegaly) LOWEST 40 + additional risk factors for ASCVD ▪URGENT: performed within 24-48h d/t threat to life or limb 2.3% CXR: ▪Time-Sensitive: performed within 1-6wks to avoid negative outcomes ✗ thoracic/major upper abdominal surgery + pt >50yo ▪ELECTIVE: performed within 12mo 0.4% symptomatic cardiopulmonary disease (e.g., COPD, CHF), BMI >40 Cardiac Risk RCRI: predict risk of major adverse cardiac events (MACE) Cardiac Emergent: proceed directly to surgery but identify RFs that affect perioperative management Assessment MACE ⇢ MI, cardiac arrest, cardiac death Management All other patients: calculate risk of MACE Application: screening for all pts undergoing major surgery Approach RCRI 0-1 (risk 20 pack-years), impaired cognition function dependency or prior stroke, preop sepsis, low albumin, OSA Acute RTI: increases risk of perioperative pulmonary/airway complications consider delaying surgery to treat infection ALL patients should be screened for Chronic Pulmonary Disease (asthma, COPD): ⇣ risk by preop optimization of pulmonary function OSA using validated tool wheezing ⇢ preop bronchodilator therapy +/- steroids e.g., STOP-BANG COPD ⇢ antibiotics MAY be beneficial in pts w/ increased sputum production or purulence OSA associated w/ double risk for postop pulmonary complications smoking cessation (only ⇣ risk if initiated 1-2mo before surgery) Hepatic Risk Chronic Liver Disease ⇢ calculate MELD score or Child-Pugh Class Hepatic Assessment Management Approach Acute Hepatitis: delay surgery until LFTs improve Chronic Liver Disease: MELD 20, Child-Pugh Class C: delay nonurgent surgery until score/class improves PREOP EVAL PREOP EVAL Renal Risk pts w/ CKD are at increased risk of postop AKI Hematologic History unknown/suggestive of bleeding disorder ⇢ PT, aPTT, platelet count Assessment & MCC complication for dialysis patients ⇢ hyperkalemia Risk Venous Thromboembolism (VTE): Management Assessment & assess all patients for VTE risk factors Chronic Kidney Disease (CKD) Preop Management: Management Thromboprophylaxis Recommended: check preop eGFR ~1mo before surgery, treat associated HTN pts >40yo or undergoing major general procedures dialysis pts should be dialyzed within 24h of surgery to optimize creatinine, electrolytes, & uremic platelet dysfunction Anemia: *pts on peritoneal dialysis may temporarily need hemodialysis for intraabdominal procedures obtain iron studies in anemic pts if planned surgery is associated w/ significant blood loss consider delaying elective surgery to correct anemia w/ treatable cause (e.g., iron therapy) Prevention of Postoperative AKI: AABB recommends preoperative transfusion for: optimize kidney perfusion for pts at risk of perioperative hypotension (e.g., IVF, vasopressors) Hgb 8-9% Assessment & NOT needed: Management Management any patient taking any dose of steroid for 3wks SGLT-2 inhibitors: hold 3-4d prior to surgery (long t1/2 & associated ketoacidosis risk) any patient on steroids w/ clinical Cushing’s syndrome Insulin: Short-acting: hold morning of surgery intermediate-acting: give 50% of usual dose morning of surgery Long-acting: give 60-80% of usual dose before surgery Insulin pump: continue basal infusion at 60-80% of usual rate Preoperative Preoperative Medication Medication Management Management Other Preoperative Antibiotic Prophylaxis of Surgical Site Infections: Risk Factors: Preoperative Preparation determined by type of procedure & patient RFs advanced age, diabetes, obesity Assessment smoking, heavy ETOH consumption admit from long-term care facility malnutrition, immunocompromised NPO: DC solids 8h before surgery, liquids 2h before surgery FLUIDS Anatomy & Total Body Water (TBW): 50-70% of total body weight, made up of 2 compartments ⇢ ICF & ECF S/SXS of Volume Disturbances: Volume Deficit Volume Excess Physiology of Intracellular Fluid Volume (ICFV): mostly in skeletal muscle mass, 50% in females, 60% in males Generalized weight loss weight gain Body Fluids Extracellular Fluid Volume (ECFV): made up of plasma & interstitial (extravascular) fluid ⇣ skin turgor peripheral edema Interstitial ECF: anything not inside cells or plasma (i.e., between cells & vasculature) Plasma ECF: intravascular volume ⇢ venous circulation contains 70% Cardiac tachycardia ⇡ cardiac output orthostasis/hypotension ⇡ central venous pressure collapsed neck veins distended neck veins murmur Renal oliguria azotemia GI ileus bowel edema Pulmonary pulmonary edema Renal Control Total body sodium content determines ECFV of Fluids & total Na content & ECFV LOW: ⇡ kidney reabsorption of Na Electrolytes total Na content & ECFV HIGH: ⇡ kidney excretion of Na FENA: fractional excretion of Na (via urine) FENA 1% ⇢ renal wasting Distal Tubule: reabsorption of Na in exchange for K & H+ secretion JG cells release renin ⇢ cleaves angiotensinogen to angiotensin I Lungs release ACE ⇢ cleaves angiotensin I to angiotensin II Angiotensin II ▪ Stimulates posterior lobe of pituitary to release ADH ⇢ increases H2O reabsorption in collecting duct ▪ Stimulates adrenal cortex to release aldosterone ⇢ stimulates K secretion & Na reabsorption @distal tubule ▪ Leads to ⇡ Na reabsorption, ⇡ vasoconstriction, ⇡ K excretion, & ⇡ H2O retention Assessing Early Signs of Hypovolemia: tachycardia, decreased pulse pressure, orthostatic BP Input, Output, Weight: daily weight one of the best methods for assessing volume status Volume BP not persistently lowered until 20-30% of circulating volume is lost Urine Output (UO) *even without intake, must excrete 800mL/d in urine waste products Status Hypervolemia HX/PE: Normal UO: 0.5cc/kg/hr or 1-2L/d (adults), 1cc/kg/hr (kids) HX: weight gain, recent MI, SOB, orthopnea Low UO: hypovolemia, renal failure, low flow states PE: JVD, rales, S3, pitting edema, ascites High UO: hypervolemia, diabetes insipidus, osmotic diuresis, post-obstructive diuresis Hypovolemia HX/PE: Labs: electrolytes QD for ICU patients HX: weight loss, vomiting, diarrhea, burns Hypovolemia: BUN/Cr >20, FENA 7.0) EKGΔ *NOTE ⇢ poor correlation between K & EKGΔ Magnesium sulfate if digitalis toxicity CKD (uncommon until GFR 5.2mg/dL malignancy associated w/ Ca >14mg/dL Primary Hyperparathyroidism: ⇡ PTH, ⇡ Ca, ⇣ PO4 Symptomatic, >14mg/dL: Hyperparathyroidism & malignancy MCC (90%) if PTH normal/mildly ⇡ get 24h urine Ca excretion IV NS until euvolemia achieved ENDOCRINE: hyperparathyroidism, acromegaly, INCREASED INTAKE/ABSORPTION: vitamin D excess, ▪24h urine Ca >200mg ⇢ primary hyperparathyroidism adrenal insufficiency, pheochromocytoma, vitamin A excess, milk-alkali syndrome hemodialysis for refractory thyrotoxicosis MISC: granulomatous (sarcoidosis, tuberculosis), PTH 20mEq/L): severe K/Mg ⇣ or mineralocorticoid ⇡⇡, Cl repletion ≠ correction Urinary K 30mEq/L ⇢ look at BP hemodialysis an option if volume overloaded + renal dysfunction ⊕HTN ▪CHF, cirrhosis w/ ascites, nephrotic syndrome ⊘HTN: Bartter, Gitelman Acetazolamide 250-375mg ⇡ HCO3 excretion but may also ▪Liddle’s: pseudohypoaldosteronism (epithelial Na channel defect) ⊕HTN: consider mineralocorticoid excess accelerate urinary losses of potassium & phosphate ▪glycyrrhizic acid (licorice) ingestion (mimics mineralocorticoid excess) Genetic ion transport d/o: ▪Bartter ⇢ NaCl reabsorption defect in loop of Henle (mimics loops) ⊘HTN (normo/hypo) ▪Gitelman ⇢ NaCl reabsorption defect in DCT (mimics thiazides) Respiratory Acidosis (hypercapnia) ACUTE: Primary Disturbance: ⇣ pH (40) Metabolic Compensation: ⇡ HCO3 reabsorption (>24) acute lung disease (e.g., pneumonia, pulmonary edema), acute COPD/asthma exacerbation *hypoventilation (retain CO2) Expected HCO3, Acute: ⇡ [HCO3] 1mEq/L per 10mmHg ⇡ [PCO2] CNS depression d/t head trauma, postictal state, drugs (e.g., opiates, BDZs), OSA Expected HCO3, Chronic: ⇡ [HCO3] 3.5mEq/L per 10mmHg ⇡ [PCO2] S/SXS: HA, confusion, anxiety, drowsiness, tremor, blunted DTRs, myoclonic jerks, asterixis +/- papilledema *full compensation expected within 3-5d CHRONIC: ACUTE TX: CHRONIC TX: airway obstruction (e.g., COPD/asthma) noninvasive ventilation (BiPAP) to blow off CO2 directed at underlying cause respiratory muscle weakness (e.g., Myasthenia gravis, ALS, Guillain-Barre, Multiple Sclerosis) invasive ventilation (trach) sometimes needed chronic hypercapnia must be corrected slowly (i.e., over hours to S/SXS: may be well tolerated, but may have memory loss, sleep disturbances, excessive daytime sleepiness, Naloxone for opioid OD minutes) because lowering PCO2 too rapidly can cause post- personality changes hypercapnic “overshoot” alkalosis ⇢ seizures, death Respiratory Alkalosis (hypocapnia) ACUTE: **think ⇢ pain, anxiety, or hypoxemia (e.g., high altitude, pneumonia, PE, ARDS) Primary Disturbance: ⇡ pH (>7.4), ⇣ PCO2 (30mmHg Prompt decompression: emergency Syndrome when the closed muscle compartment pressure > pain & paresthesia Delta pressure 72h obstructive ⇢ intrabronchial suction via endoscope Wounds SEROMA: localized serious fluid collection not containing pus or blood, delay healing & ⇡ risk of wound infection LABS: CBC ⇢ leukocytosis Superficial: HEMATOMA: collection of blood & clot caused by unsuccessful hemostasis or coagulation suture removal, I&D, thorough irrigation, debridement blood/wound cultures pack wound, +/-ABX Surgical Site Infection (SSI): incisional skin/soft tissue or organ/space infection at recent surgery site, MC within 5-10d subsequent routine wound care Classification: Onset: Tissue Involvement: Clinical Features: +/- imaging to assess for deep Superficial Incisional ≤30d ▪skin & SQ tissue ▪purulent discharge from incision, +/- fever tissue or organ/space infection Deep, Organ/Space: ▪localized tenderness, warmth, erythema, swelling OR ⇢ exploration, washout, drainage, debridement Deep Incisional 30-90d ▪deeper soft tissue ▪purulent discharge from deep within incision, ⊕fever ABX required, pack wound (i.e., fascia, muscle layers) ▪tenderness, wound dehiscence ▪necrotizing fasciitis: cloudy gray discharge, +/- crepitus *DELAYED CLOSURE, left to heal by secondary intention Organ/Space 30-90d ▪any part deeper than fascia or ▪purulent discharge from a drain in organ/space, abscess muscle layers opened in surgery ▪⊕fever, additional features depend on organs affected Procedure: ABX: MC Pathogens: Risk Factors: NOT genital/GI tract ▪Cefazolin or Oxacillin ▪S. aureus ▪CoNS (S. epidermidis MC) patient-related: ▪steroids, smoking, diabetes, >age ▪Vancomycin or Linezolid (MRSA) ▪E. coli ▪Enterococcus spp. ▪coexisting infection at another site Perineum, axilla, ▪Ceftriaxone + Metronidazole ▪HIV/AIDS, prolonged hospital stay GI, or GU Pathogens causing necrotizing fasciitis: first 24h postop procedure-related: ▪suboptimal prep, OR venting ▪GAS (e.g., S. pyogenes), Clostridium spp. (e.g., C. perfringens) ▪ABX prophylaxis, long surgery  Cardiovascular 9% About Clinical Manifestations Diagnostics Management Abdominal Aortic Focal aortic dilation >1.5 normal (>3.0 Most pts are asymptomatic – may be found CT w/ contrast: best initial test in Symptomatic or ruptured: Aneurysm (AAA) considered aneurysmal) – infrarenal incidentally on imaging or in pts w/ an symptomatic, hemodynamically stable IMMEDIATE SURGICAL REPAIR MC site abdominal bruit or a palpable abdominal pts to deter presence, size, & extent -endovascular stent graft mass -open repair PATHO: proteolytic degeneration of Focused bedside U/S: may be initial BBs reduce shearing forces, decreases expansion & rupture risk aortic wall & connective tissue Symptomatic (unruptured): study of choice in hemodynamically inflammation abdominal, flank, or back pain unstable pts w/ suspected AAA AAA Screening: one-time screening via abdominal U/S in men 65-75yrs on exam, an abdominal bruit may be who ever smoked Risk Factors: auscultated & a palpable abdominal mass Pts w/ known AAA who present w/ smoking (main modifiable), >60yrs, may be palpated classic sxs or signs of rupture can be Caucasians, males taken to the operative room for surgical hyperlipidemia, atherosclerosis, Symptomatic (ruptured): repair w/o preoperative imaging connective tissue disorder (Marfan), abdominal, flank, or back pain syphilis, HTN abdominal bruit Asymptomatic w/ suspected AAA: Protective Factors: female, DM, non- pulsatile mass abdominal U/S: initial test in Caucasian, moderate alcohol hypotension or syncope asymptomatic pts & to monitor consumption flank ecchymosis progression Aortoenteric fistula: presents as acute GI bleed in pts who underwent prior aortic grafting Aortic Dissection Tear through the innermost layer of Chest pain: sudden onset severe, tearing CT angiogram, MR angiogram, TEE Acute proximal: surgical the aorta (intima) due to cystic medial (ripping, knife-like) chest/upper back pain; - preoperative BP control necrosis may radiate between the scapulae CXR: widened mediastinum ascending: anterior chest pain Descending/distal: medical Ascending MC near the aortic arch or aortic arch: neck/jaw pain - non-selective BBs (labetalol) left subclavian descending: interscapular pain +/- sodium nitroprusside descending - SBP rapidly lowered to a goal of 100-120 within 20min aortic arch Unequal BP in both arms Risk Factors: HTN (most important) age >50yrs men, vasculitis, trauma, family hx Turner’s syndrome collagen d/o (Marfan, Ehlers-Danlos), pregnancy  About Clinical Manifestations Diagnostics Management Peripheral Arterial Atherosclerotic disease of the Intermittent claudication – MC sxs (lower extremity pain w/ ambulation) ABI: most useful screening test Supportive: first line therapy – exercise (fixed Disease arteries of the lower extremities + PAD if 50% occlusion), decreased capillary refill skin: atrophic changes – muscle atrophy, thin/shiny skin, hair loss, thickened nails cool limbs, areas of necrosis; usually no edema LATERAL MALLEOLUS ULCERS color: pale on elevation, dependent rubor (dusky red w/ dependency) Acute Arterial Acute limb ischemia – rapidly 6 Ps: paresthesias (often early), pain, pallor, pulselessness, Bedside arterial doppler to assess for Reperfusion mainstay of tx – surgical bypass, Occlusion developing or sudden decrease in poikilothermia, paralysis (late finding associated w/ a worse prognosis); pulses surgical or catheter based limb perfusion sxs usually distal to the occlusion thromboembolectomy, endarterectomy; VASCULAR Etiologies: thrombotic occlusion CT angiography or catheter angiography thrombolytic therapy or percutaneous EMERGENCY MC (w/ preexisting peripheral Decreased capillary refill, decreased or absent pulses, cool temperature angioplasty arterial disease) – MC in the An immediately threatened limb may superficial femoral or popliteal undergo further evaluation & treatment Supportive: pain control, fluid resuscitation, UFH artery in a surgical suite About Clinical Manifestations Management Varicose Veins Dilation of superficial veins due to failure of the Most are asymptomatic but may present due to cosmetic issues Conservative: compression stockings, leg venous valves in the saphenous veins, leading to elevation, pain control retrograde flow, venous stasis, & pooling of blood Dull ache or pressure sensation; pain is worse w/ prolonged standing or sitting w/ the leg dependent & is relieved w/ elevation Ablation: catheter-based endovenous thermal Risk Factors: family hx, female, increased age, ablation (laser or radiofrequency) standing for long periods, obesity, increased PE: dilated visible veins, telangiectasias, swelling, discoloration, venous stasis ulcers: severe varicosities estrogen (OCP, pregnancy), chronic venous resulting in skin ulcerations; +/- mild ankle edema Ligation & stripping, sclerotherapy insufficiency Chronic Venous Changes due to venous HTN of the lower Leg pain worsened w/ prolonged standing, prolonged sitting w/ the feet dependent Conservative: initial management of choice – leg Insufficiency extremities as a result of venous valvular elevation, compression stockings, exercise, incompetency Leg pain improved w/ ambulation & leg elevation weight management MC occurs after superficial thrombophlebitis, after Pain classically described as a burning, aching, throbbing, cramping, or “heavy leg” Treat the underlying cause – surgical DVT or trauma to the affected leg intervention usually reserved for pts not PE: responsive to conservative therapy stasis dermatitis: itchy eczematous rash (inflammatory papules, crusts, or scales), excoriations, weeping erosions & brownish or dark purple hyperpigmentation of the skin (hemosiderin deposition) Ulcer management: compression bandaging venous stasis ulcers systems (e.g., zinc impregnated gauze), wound MEDIAL MALLEOLUS ULCERS debridement if needed, ASA (accelerates dependent pitting leg edema, increased leg circumference, varicosities & erythema w/ normal pulse healing) & temperature atrophic blanche: atrophic, hypopigmented areas w/ telangiectasias & punctate red dots  About Clinical Manifestations Diagnostics Management Stable manifestation of stable atherosclerotic CAD HX: man >50y or woman >60y; complains of LABS: to evaluate for risk factors Acute TX: sublingual nitroglycerin q5min up to 3x Angina episodic chest discomfort – heaviness, pressure, total cholesterol, LDL, HDL, triglycerides, RF TX: hyperlipidemia, HTN, DM, smoking cessation Pectoris Myocardial ischemia: myocardial oxygen demand exceeds squeezing, smothering, choking (not sharp) glucose (A1C), creatinine, hematocrit oxygen supply pt often localizes pain over sternum Prevention Therapy: typically lasts 2-30min UA: examine for DM & renal disease (including 1) beta blockers, first-line therapy results when a fixed coronary plaque prevents sufficient may radiate to arms, back, jaw/neck, shoulders microalbuminuria) 2) nitrates, take ~5min before activity blood supply through a coronary artery at times of increased 3) aspirin 75-325mg/d O2 demand, resulting in predictable chest discomfort during Episodes caused by exertion/emotional upset & CBC: anemia can aggravate angina 4) high-intensity statin regardless of baseline LDL times of physical or emotional stress relieved by rest/NTG TFTs: hyperthyroidism can aggravate angina, hypothyroidism can lead to atherosclerosis ACEI/ARBs: known benefit for pts w/ HTN, diabetes, Atypical angina, “anginal equivalents” ↓ LVEF 3mg/L is an independent risk factor for CCBs: indicated if beta blockers are contraindicated, women, diabetics, elderly myocardial ischemia poorly tolerated, or ineffective Ranolazine: anti-anginal medication, useful for pts Chest pain classification: EKG: +/- ST depressions, T wave inversions; w/ chronic angina despite standard medical therapy EKG Ischemia Findings: substernal normal in absence of symptoms T wave flattening, hyperacute T waves (peaked) provoked by exertion/emotional stress Indications for Revascularization w/ CABG: T wave inversions (TWI) relieved w/ rest/NTG ⊖ serum markers chronic stable angina w/ 3-vessel disease ST depressions 3/3 = typical angina (definite) Stress testing: nuclear perfusion imaging, ECHO 2-vessel disease w/ prominent LAD involvement 2/3 = atypical angina (probable) 1/2-vessel disease w/ high-risk features 0-1/3 = noncardiac chest pain Gold standard: cardiac catheterization, – LV dysfunction coronary CT angiography >50% stenosis of left artery refractory symptoms, chronic angina Coronary Vasospasm About Clinical Manifestations Diagnostics Management Vasospastic Angina PATHO: focal or diffuse spasm of epicardial Chest pain/angina characteristics: COVADIS Diagnostic Criteria: sublingual NTG (Prinzmetal or coronary artery resulting in dynamic high-grade CP indistinguishable from obstructive CAD 1) nitrate-responsive angina smoking cessation Variant Angina) obstruction occurs predominantly at rest, often 12am to early morning 2) transient ischemic EKG changes ASCVD risk factor modification vascular smooth muscle hyperreactivity lasts 5-15 minutes, responds rapidly to NTG 3) angiographic evidence of coronary artery spasm – defined as >90% constriction CCBs: diltiazem, amlodipine, etc. Risk Factors: female, 0.30s Metoprolol Indications: ALL ACS pts should have BB initiated within first 24h & continued indefinitely *if s/sxs of active HF, delay initiation until HF under control Atenolol *mortality benefit ADRs: sexual dysfunction, sedation, fatigue, depression Warnings: do not stop BB abruptly (rebound angina), may mask s/sxs of hypoglycemia Statins Simvastatin Atorvastatin MOA: inhibit the rate-limiting step in hepatic cholesterol synthesis via inhibition HMG-CoA Contraindications: active hepatic disease, persistent elevated LFTs, Pravastatin Rosuvastatin reductase; increase LDL receptors, promoting LDL clearance; reduce triglycerides pregnancy/breastfeeding Lovastatin Indications: best drug to decrease LDL; have been shown to decrease cardiovascular ARDs: muscle damage (myositis, rhabdomyolysis), ↑ LFTs, hepatitis, complications GI sxs, DM FIBRINOLYSIS RX About Tissue Plasminogen Alteplase (tPA) MOA: activate plasminogen to plasmin which degrades fibrin ADRs: bleeding, hypotension Activators Reteplase (rPA) Indications: STEMI ONLY, alternative if PCI unavailable within 120min & sxs onset ≤12h, less Monitoring: BP q30-60min, EKG for arrhythmias/ST changes, Tenecteplase (TKA) evidence if sxs onset 12-24h cTnI/cTnT q4h x24h Absolute Contraindications: active internal bleed, any hx of ICH, CVA in past 1y, known intracranial neoplasm, suspected aortic dissection or pericarditis Discharge: continue DAPT ≥1y Dyspnea on Exertion Arrhythmia: AFIB, inappropriate sinus tachycardia, sick sinus syndrome/bradycardia HX: palpitations, syncope PE: irregular rhythm, pauses DX: EKG, event recorder, Holter monitor, stress testing Myocardial: cardiomyopathies, coronary ischemia HX: DOE, PND, orthopnea, chest pain or tightness, prior coronary artery disease or AFIB PE: edema, JVD, S3, displaced cardiac apical impulse, hepatojugular reflux, murmur, crackles, wheezing, tachycardia, S4 DX: EKG, BNP, echo, stress testing, coronary angiography Restrictive: constrictive pericarditis, pericardial effusion/tamponade HX: chest pain, dyspnea PE: paradoxical pulse (exaggerated variation in BP w/ respiration) DX: EKG showing low voltage QRS w/ electric alternans; echo w/ increased pericardial fluid; radiograph: water bottle heart Valvular: aortic insufficiency/stenosis, congenital heart disease, mitral valve insufficiency/stenosis HX: DOE PE: murmur, JVD DX: echo  About Clinical Manifestations Diagnostics Management Dilated Systolic dysfunction, leading to a dilated, weak heart Systolic heart failure Echo: ACEI, BB Cardiomyopathy L-sided failure: dyspnea, fatigue left ventricular dilation, thin ventricular walls diuretics Risk Factors: MC 20-60yrs, men R-sided failure: peripheral edema, JVD, decreased EF, ventricular hypokinesis (MC!!) hepatomegaly, GI sxs automated implantable Etiologies: embolic events, arrhythmias Chest x-ray: cardiomegaly, pulmonary edema, cardioverter/defibrillator if EF L-sided HF Echo: Treat the underlying disorder Cardiomyopathy impedes ventricular filling (decreased compliance); the R-sided failure: peripheral edema, JVD, non-dilated ventricles w/ normal thickness stiff ventricle fills w/ great effort hepatomegaly, ascites, GI sxs diastolic dysfunction L-sided failure: dyspnea, fatigue marked dilation of both atria Etiologies: infiltrative diseases: amyloidosis MC, sarcoidosis, Kussmaul’s sign: increased in JVP w/ inspiration hemochromatosis Stress Transient regional systolic dysfunction of the LV that Similar to ACS EKG: ST elevations (esp. in anterior leads); may Initial: (Takotsubo) can imitate MI but is associated w/ absence of substernal chest pain have ST depressions - ASA, NTG, BB, heparin, coronary angiography Cardiomyopathy significant obstructive coronary artery disease or dyspnea, syncope evidence of plaque rupture Cardiac enzymes: often + Short-term: conservative & supportive - BBs Risk Factors: postmenopausal women exposed to Coronary angiography: absence of acute plaque - ACEI for 3-6mo physical or emotional stress rupture or obstructive coronary disease - serial imaging to assess for improvement - anticoagulation in some w/ severe LV PATHO: thought to be multifactorial, including Echo: transient regional left ventricular systolic dysfunction or if thrombus present catecholamine surge during physical or emotional dysfunction, esp. apical left ventricular stress, microvascular dysfunction, & coronary artery ballooning; usually performed after ACS has spasm been r/o  About Clinical Manifestations Diagnostics Management Pericarditis Inflammation of the pericardium, the outer layer of Chest pain: sudden onset EKG: diffuse ST elevations in the precordial leads Anti-inflammatory meds: NSAIDs or ASA x7-14d the heart pleuritic (sharp, worse w/ inspiration) w/ associated PR depressions in those leads - colchicine second line Fibrinous or serofibrinous: e.g., post-MI, infectious persistent postural (worse when supine & improved w/ Dressler Syndrome: ASA or colchicine Etiologies: sitting forward) - avoid NSAIDs because they can interfere w/ 2 MCC – idiopathic, viral (Coxsackievirus & pain may radiate to back, shoulder, neck, arm, or myocardial scar formation echovirus) epigastric area Dressler syndrome (post MI pericarditis + fever + pleural effusion) Pericardial friction rub: best heard at end expiration while upright & leaning forward Pericardial Accumulation of fluid in the pericardial space chest pain (if associated w/ acute pericarditis) Echo: test of choice – increased fluid in Treat the underlying cause (acute pericarditis) Effusion Normally, about 5-15ml of fluid is in the pericardial dyspnea, fatigue pericardial space Serial echo if needed space EKG: electrical alternans (alternating amplitudes Etiologies: viral, idiopathic, immune, malignancy – lung PE: decreased (muffled) heart sounds (due to of the QRS complexes); low QRS voltage Large effusions may need pericardiocentesis for cancer MC, breast second MC, aortic dissection, fluid) CXR: “water bottle” heart symptomatic relief uremia Cardiac Pericardial effusion causing significant pressure on Beck’s triad: distant (muffled) heart sounds + ↑ Echo: pericardial effusion + diastolic collapse of IMMEDIATE PERICARDIOCENTESIS to remove Tamponade the heart, impeding cardiac filling, leading to JVP + systemic hypotension cardiac chambers the pressure decreased CO & shock - volume resuscitation & pressor support if EMERGENCY Pulsus paradoxus: exaggerated (>10mmHg) ↓ in EKG: low voltage QRS complexes, electrical needed Etiologies: complication of acute pericarditis or systolic pressure w/ inspiration alternans - pericardial window drainage if recurrent trauma; malignancy MC non-traumatic cause Dyspnea, fatigue, peripheral edema, shock, reflex CXR: may show enlarged cardiac silhouette tachycardia, cool extremities Right heart catheterization: equalization of pressures in diastole Constrictive Loss of pericardial elasticity (thickening, fibrosis, dyspnea (MC), fatigue, orthopnea CXR: pericardial calcification may be seen esp. on Diuretics for symptom relief as well as Pericarditis calcification) leading to restriction of ventricular lateral view, clear lung fields reduction of edema & venous pressure diastolic filling Right-sided HF signs: normal or slightly increased heart size ↑ JVD, peripheral edema, N/V square root sign on cardiac catheterization Definitive: pericardiectomy PATHO: fibrosis limits ventricular filling, decreased ↑ hepatojugular reflex stroke volume & cardiac output Kussmaul’s sign (the lack of an inspiratory Echo: pericardial thickening &/or calcification decline or an ↑ in jugular vein pressure w/ (also used to r/o restrictive cardiomyopathy) Etiologies: any cause of acute pericarditis inspiration) ”square root” sign – early diastolic dip followed US – idiopathic & viral MCC by a plateau if diastasis worldwide – TB MCC Pericardial knock: high pitched diastolic sound similar to S3 (sudden cessation of ventricular CT scan/MRI: pericardial thickening or filling) calcification Valvular Disorders About S/Sxs Murmur Diagnostics Management Aortic Stenosis PATHO: LV outflow obstruction leads to a Once symptomatic, lifespan is Systolic crescendo-decrescendo murmur Echo: Surgical therapy: replacement only (AS) fixed CO, ↑ afterload, LVH, & eventually dramatically reduced location: RUSB, radiates to carotid artery small aortic orifice effective treatment lV failure LVH indications: symptomatic, ↓ EF, or area SYSTOLIC dyspnea ↑ intensity: calcified aortic valve 65yrs - least aggressive, best prognosis - slow growing parafollicular C cells - most aggressive - MC 40-60yrs - 90% sporadic - poor prognosis Risk Factors: - 10% associated w/ MEN IIa or IIb MC after radiation exposure of head/neck Risk Factors: Presentation: rapid growth, compressive sxs ↑ incidence w/ iodine deficiency Labs: Presentation: painless thyroid nodule METS: distant METS MC than local (lung MC) ↑ calcitonin PE: “rock” hard thyroid mass “Follicular goes Far” Workup: Management: Management: FNA Workup: - total thyroidectomy - most not amenable to surgical resection TFTs usually normal FNA cannot distinguish from follicular adenoma - external beam radiation, chemo definitive: post-op histologic testing Monitoring: - palliative tracheostomy to maintain airway Management: - calcitonin to monitor for recurrence or residual - thyroidectomy (total or near total) Management: - post-op levothyroxine - thyroidectomy (total or near total) - post-op levothyroxine Post-Op Monitoring: - thyroglobulin Post-Op Monitoring: - TSH - thyroglobulin - neck U/S - TSH - neck U/S Thyroid Nodule About Clinical Manifestations Diagnostics Management >90% benign Most are asymptomatic TFTs – initial test Surgical excision if thyroid cancer is Compressive sxs: difficulty swallowing or breathing, TSH subnormal/low à RAIU suspected Risk Factors: extremes of age, hx of hoarseness TSH normal/high à FNA w/ bx head/neck radiation Functional nodules: rare – presents w/ thyrotoxicosis Observation + follow-up U/S every 6-12mo Thyroid U/S Benign: PE: suspicious: irregular margins, hypoechoic, central vascularity, follicular adenoma (colloid) MC nodule benign: varied presentation documented nodule growth adenomas, cysts, localized thyroiditis malignant: rapid growth, fixed, no movement w/ swallowing FNA: best to evaluate etiology performed in nodules >1.5cm w/ normal TSH or highly