Surgery EOR Study Guide PDF

GI INFO CM DX/ Imaging Labs TX Cholecystitis Gallbladder (cystic duct) Acute→ suddenly, severe & Palpable GB Le...

GI INFO CM DX/ Imaging Labs TX Cholecystitis Gallbladder (cystic duct) Acute→ suddenly, severe & Palpable GB Leukocytosis with left NPO, IVF, cephalosporin obstruction by stone→ steady pain in upper abd Murphy’s sign shift +metronidazole inflammation/ infection ○ Inflamm might cause fluid Boas sign (referred pain to INC bili after 24 hrs, ALK Cholecystectomy (elective) ○ 50-80% E. coli filled gallbladder and thick subscapular d/t phrenic nerve phos, LFTs Meperidine (morphine assoc Acute acalculous wall irritation) with spasm of sphincter of cholecystitis→ MC from a Chronic→ repeated attacks of US→ initial TOC oddi) seriously ill patient; usu pain (biliary colic) ○ Thickened GB >3mm from biliary stasis- absence ○ Occur when gallstones ○ Distended GB of cholecystokinin (dec periodically block the cystic ○ Gallstones contraction of GB) duct ○ Pericholecystic fluid Chronic cholecystitis→ Biliary colic: episodic RUQ/ ○ Sonographic murphy sign assoc from gallstones, epigastric pain beginning HIDA scan: GS* AKA strawberry GB (secondary abruptly, cont. in duration, cholescintigraphy from cholesterol resolves slowly (lasting 30-1hr) ○ GB ejection fraction and if submucosal aggregation)--> ○ Assoc. w/ nausea from fatty stone is present in cystic duct porcelain GB (premalignant foods and large meals ○ If pt is fasting, HIDA may show condition) Low grade fever, n/v falsely dec EF (inject morphine Could present w/ jaundice bc of or CCK if that’s the case) the INC bili (more assoc with ERCP→ can identify cause and choledocholithiasis) location and extent of biliary Hypoactive bowel sounds obstruction (diagnostic and indication perforation→ systemic therapeutic) (use i9f 100% sure signs of toxicity (tachyC and INC its GB problem) RR), INC abd pain, rebound MRCP→ like an MRI image of tenderness gallbladder (use if not 100% sure if its a GB problem) Pancreatitis MCC: cholelithiasis or Epigastric pain radiating to back/ Hemorrhagic panc Leukocytosis Stop oral intake; fluid alcohol abuse (chronic) other quadrant ○ Gray turner (flank bruising) INC amylase (may be resuscitation - 90% recover Also from trauma, Pain is better with leaning ○ Cullen sign (umbilical) normal after 48-72hrs) Pain mgmt (demerol) hyperlipidemia, drugs, forward, sitting, lies in fetal Left sided exudative pleural INC lipase (more Consider abx (not used PPX) HYPERca+, penetrating PUD, position effusion SENSITIVE) 3x greater- imipenem for necrotizing meds n/v/f CT is TOC INC in 7-14days pancreatitis Chronic: loss of endocrine dehydration/ shock AXR→ sentinel loop= localized Mild hyperbilirubinemia/ ERCP if biliary sepsis is function Peritonitis ileus– dilated small bowel in LUQ- bilirubinuria suspected (only effective in ○ Inflammation resolved tachyC >130→ grave prognosis colon cutoff sign HYPOca+ obstructive jaundice) but with resultant of Hypovolemia Hyperglycemia Chronic→ oral panc. Enzyme damage to gland ARDS replacement, low fat diet, characterized by fibrosis, Acute→ surgical removal of damaged calcification and ductal ○ Isolated episode of abd pain part inflammation accompanied by elevations of STOP DRINKING blood enzyme levels Indications for surgery→ ○ >80% related to acute panc ○ Pain limits function usu from biliary stones or ○ Intractable pain despite alcohol use non-narcotic analgesics Chronic→ ○ Absence of alcohol intake ○ Triad of steatorrhea, calcifications, DM ○ Possible acute pancreatitis episodes Anal Fissure Painful linear lesions in the Severe tearing pain when Severe painful BM causing pt to **surgery route→ major 80% resolve spontaneously distal anal canal pooping, accompanied by refrain from having BM→ complication would be 1st line→ analgesics, sitz MC found in posterior hematochezia constipation, bright red blood irreversible fecal bath, bulking agents, INC midline Bright red blood in stool or toilet from rectum, rectal pain incontinence fluids to avoid straining May involve full thickness of paper 2nd line→ topical mucosa if untreated Skin tags if chronic nitroglycerin, silver nitrate, nifedipine ointment, botox High fiber diet Anorectal From bacterial infx of anal Throbbing rectal pain Abscess→ I&D; no abx Abscess/ ducts/ glands ○ Worse with sitting, coughing, Fistula ○ S.aureus, E.coli pooping MC posterior midline Appendicitis Obstruction of appendix Initial sx→ anorexia, Rectrocecal appendicitis= pain on Leukocytosis (10-20k)- Appendectomy MC d/t fecalith periumbilical/ epigastric pain, rectal exam higher levels suggest If suspect perforation or ○ Or inflamm, malignancy, intermittent→ constant and Rovsing perf/ peritonitis abscess→ ABX before and foreign body (collagen worsened RLQ pain (McBurney’s Obturator Some hematuria/ pyuria after surgery vascular dz, IBD) point) Psoas Cefotetan 2 g IV before MC surgical emergency n/v/ low-grade fever Mcburney’s surgery (one dose) to prevent MC 10-30y Rebound tenderness Initial→ US intra-abd infection and wound 20% perf/ peritonitis→ high CT is more sensitive and confirms infection fever, generalized abd pain, INC dx Abx not required if leuko uncomplicated Bariatric Only proven method to Guidelines: BMI>40 or >35 w/ Restrictive: less weight loss, not as much morbidity surgery maintain weight loss and medical problem, failed other →Adjustable gastric banding (AGB): SMALLEST amount of weight loss reduce obesity-related non-surgical programs, must be ○ BMI >30-35 w/ comorbid conditions M&M psychologically stable and able ○ Ideal for volume eater; trains you to eat and chew slower Complications: to follow post-op instructions ○ Proximal gastric pouch created using inflatable band and access port placed  ○ Early: anastomotic leak, ○ 35-45% weight loss in first few years DVT, PE, bleeding, infx, ○ Fewer complications but need more f/u for band adjustment; comp.: regurg, prolapse, annual splenic injury check-ups for GI band; less risk but less weight loss ○ Late: malnutrition, →Vertical banded gastroplasty (VBG) marginal ulcer and →Sleeve gastrectomy (SG): 85% stomach removed and stomach takes shape of sleeve; weight loss less anastomotic strictures, than RNYGB but higher than AGB: MEDIUM weight loss internal hernia, ○ Reduces stomach to DEC with removal esophageal dilatation, ○ BMI>35 dumping syndrome (usu ○ Complications: lack of hunger, 70% weight loss by 2 yrs occurs when pt attempts Malabsorptive: more weight loss but issues w/ malnutrition/ nutrient absorption to eat a large amount of ○ Biliopancreatic diversion: not popular simple sugars- they move Combo of restrictive/ malabsorption - MOST weight loss from stomach to bowel →Roux-en-Y gastric bypass (RNYGB): MC* for severe obesity - proximal gastric pouch created by too quick→ fullness, transecting stomach; 75-85% excess body weight lost in first 2 yrs; less severe nutrition problems cramping, pain, n/v/d, ○ Bypass of most stomach, entire duodenum, part of small intestine seating, flushing, tachy) ○ Pouch is restrictive, causing fullness, roux limb limits absorption ○ BMI>35 ○ Complications: dumping syndrome, lifelong micronutrient supplementation (B1. B12, folate. Vitamin C) and vitamins ADEK and minerals Bowel SBO MC from adhesions Complete strangulation→ SBO: high pitched tinkles and Dehydration and NPO, NG suctioning, IVF Obstruction ○ 2nd MCC is hernias ○ Infarction, necrosis, peritonitis, visible peristalsis→ hypoactive electrolyte imbalance (partial obs) ○ Also from neoplasms, IBD, death bowel sounds in late obstruction Urgent surgical consult volvulus abdominal pain, distention XR: air fluid levels in step ladder necessary when mechanical LBO MCC is neoplasm SBO: vomiting, obstipation patterns; dilated bowel loops obstruction is suspected (esp ○ Also from strictures, (severe) If radiograph inconclusive→ CT large bowel) hernias, volvulus, ○ Crampy abd pain, vomiting w/ contrast ** metabolic alk is MC intussusception, fecal follows the pain, diarrhea acid-base disturbance post-op impaction (early); mild pain→ severe (from vol. contraction combined LBO: afebrile and tachy, shock w/ gastric fluid loss) may ensue **NG decompression post-op causes the stomach to lose acid ** HCO3 inc to replenish HCl acid ** pt also loses K+ from gastric fluid during NG suctioning ** combo of volume contraction and post-op measures causes hypoCl-, hypoK+ metabolic alkalosis Volvulus Twisting of any part of the Abd pain Endoscopic decompression bowel in itself Distention Surgical correction MC sigmoid n/v/f ○ & cecum tachy Primary Autoimmune, progressive Progressive jaundice ERCP= GS (inc risk of developing INC ALP (3-5x normal) Liver transplant sclerosing cholestasis w/ diffuse Pruritus cholangiocarcinoma and INC GGT (cholestasis) steroids/ immune meds (no sig cholangitis fibrosis of intrahepatic and RUQ pain pancreatitis bc ercp can push INC ALT, AST, bili, IgM benefit) extrahepatic ducts Hepatomegaly stone and irritate the pancreas) +P-ANCA Rare Splenomegaly MC assoc w/ IBD ○ 90% have UC; +/- crohns MC men 20-40y/o Ascending Biliary tract infx secondary Charcot’s triad INC liver enzymes PCN + aminoglycoside Cholangitis to obstruction by gallstone ○ RUQ pain, jaundice, fever Decompression of biliary tree (usu from Reynold’s pentad: all of above via ERCP choledocholithiasis) +shock, +AMS Cholelithiasis Gallstones w/ NO MC asx US- TOC Asx– may resolve or use oral INFLAMMATION Biliary colic→ episodic RUQ/ bile dissolution 90% cholesterol epigastric pain beginning Cholecystectomy RF: 5 F’s abruptly, continuous in duration, Complications: choledocho→ ○ Female resolves slowly, lasting 30 gallstones in in common bile ○ Fertile min-hours (((ROSH says 3 hrs duct→ +/- biliary colic and ○ Forty after a meal))); assoc. w/ nausea jaundice ○ Fair from fatty foods or large meals ○ Dx: MRCP ○ Fat ○ Tx: stone extraction via ERCP RF: OCP’s (INC estrogen), (or if ur more sure its GB- native americans, bile just do ercp since its stasis, chronic hemolysis, diagnostic and therapeutic) cirrhosis, infx, rapid weight loss, IBD, TPN, fibrates, INC triglycerides Diarrhea INC frequency or volume of Secretory (large volumes w/o WBC in stool= inflammatory IVF= mainstay of gastroenteritis; PO preferred stool 3+ liquid or semi solid inflammation) indicates infx, Cultures for bacterial agents, Diet: bland low residue (BRAT/ crackers, boiled veggies, stools daily for at least 2-3 pancreatic insufficiency, microscopy for parasites, toxin soup) consec days ingestion of preformed bacterial identification Antimotility agents: in pt 50 y/o with new onset should hyperCa+ INC insoluble fiber and fluid from 3 stools/ day to 3 be eval for colon cancer +/- KUB intake and exercise stools/ week If over 2weeks and nothing DEC in stool volume and INC works then should be further in stool firmness investigated for underlying accompanied by straining cause Diverticular dz Diverticula→ small mucosal Fever CT T.O.C INC WBC f/u after 6 weeks with herniations protruding LLQ pain + guaiac stool colonoscopy to make sure no through intestinal and SM n/v/d/c colon CA layer along vasa recta Diverticulosis usu asx but MC -itis→ CLD, ○ Sigmoid colon MC d/t cause of acute lower GI bleed cipro+metronidazole, LOW highest intraluminal Bloating fiber diet pressure Can pass gas -osis→ HIGH fiber diet, fiber Diverticulosis→ non supplements, bleeding stops inflamed diverticula (assoc in 90% w/ low fiber diet*, constipation, obesity) Diverticulitis→ inflamed diverticula secondary to obstruction/ fecaliths (infx) → distention Esophageal Squamous→ MC assoc w/ Solid food dysphagia Upper endoscopy w/ bx Esophageal resection Neoplasms tobacco and alcohol Odynophagia XRT ○ Also in DEC veggies, fruits, Weight loss Chemo achalasia, hot beverages, Chest pain Commonly spreads to noxious stimuli in men, Anorexia mediastinum; endoscopy nitrates Cough screening in pts with barrett’s ○ MC in upper ⅓ Hoarseness q3-5yrs esophagus; peaks Reflux ○ Barretts→ transition of 50-70y/o Hematemesis squamous to columnar ○ INC in african americans +/- virchow’s node epithelium Adenocarcinoma→ 50-80% HYPERca+ in pts with squamous in US cell (d/t ectopic PTH related ○ Presents in younger protein tumor secretion) patients and usually EARLY ○ Usu complication of GERD/ barrett's (most serious complication of barrett's)/ obesity ○ Lower ⅓ of esophag. Esophageal Esophageal web: thin Plummar-vinson syndrome: Barium esophagram (swallow) Endoscopic dilation of the strictures membranes in mid-upper dysphagia + esophageal webs+ area esophagus, may be iron deficiency anemia; atrophic congenital glossitis, angular cheilitis, Schatzki ring: mucosa lower koilonychias, splenomegaly esophag constrictions at Dysphagia (esp w/ solids) squamocolumnar junction ○ MC assoc w/ hiatal hernia Gastric Adenocarcinoma MC Indigestion Upper endoscopy w/ bx Gastrectomy Carcinoma MC males >40 and present weight loss ○ Linitis plastica (diffuse ○ Disease encasement of the usu in late dz early satiety thickening of stomach wall d/t hepatic artery, vascular RF: H. pylori abdominal pain/ fullness cancer infiltration (worst type)) involvement of aorta, ○ Salted, cured, smoked, Nausea proximal splenic artery,  pickled foods containing Postprandial vomiting distant metastasis = nitrites Dysphagia unresectable (cant operate) ○ Also RF: pernicious Melena XRT anemia, chronic atrophic Hematemesis Chemo gastritis, achlorhydria, Iron deficiency anemia Poor prognosis smoking, alcohol, blood Signs of metastasis→ type A ○ Virchow’s node, sister mary joseph node, ovarian METS, palpable nodule on rectal exam (blumer’s shelf), left axillary node involvement (irish sign) GERD Transient relaxation of Heartburn (pyrosis)** Endoscopy 1st line Antacids and H2 receptor LES→ gastric acid reflux→ ○ Retrosternal and ○ Use w/ pt over 45 and new blockers esophageal mucosal injury postprandial (30-60min onset sx, longstanding or PPIs if severe Complications: esophagitis, after eating) recurrent sx, failure to AVOID→ beta agonist, alpha esophageal stricture, ○ INC in supine position respond to therapy or sx antagonist, nitrates, CCB, barrett’s, adenocarcinoma Regurg (water brash or sour taste indicating more severe anticholinergics, theophylline, ○ Barrett’s→ esophageal in mouth) conditions like anemia, morphine, meperidine, squamous epithelium Dysphagia recurrent vomiting diazepam, barbiturate agents replaced by Cough at night (acid aspiration at r/o MI (DEC LES pressure) precancerous columnar lungs causing irritation) Esophageal manometry: DEC LES Elevate head of bed 6 inches cells from cardia of the Halitosis, cough, hiccupping, pressure; for achalasia Avoid recumbency for 3 hrs stomach laryngitis, sore throat, atypical 24hr ambulatory pH - GS but usu after eating, eat small meals Predisposing factors: DM, chest pain not done Avoid fatty/ spicy foods, smoking, obesity, hiatal Atypical sx→ hoarseness, citrus, chocolate, caffeinated hernia aspiration pneumonia, asthma, products, peppermint, alcohol, non-cardiac chest pain, weight smoking loss ALARM SX→ dysphagia, ordynophagia, weight loss, bleeding Hematemsis/ ETI: Vomiting blood PE: signs of HYPOVOLEMIA CBC NGT lavage: if unclear pt has GI bleed ○ PUD Coffee ground emesis ○ mild/mod ( resting Chems ongoing bleeding ○ Esophageal ulcer Melena tachy LFTs IV access→ 2 large bore ○ Mallory-weiss tear black/tarry stools ○ Mod (>15%)--> orthostatic Coags (18g)IV FLUIDS!!! ○ Variceal hemorrhage/ Orthostatic dizziness HoTN ECGs/ cardiac enzymes Transfuse if Hgb 40%)--> supine for those at risk of MI risk OR 7 ○ Malignancy Severe palpitations If INR is >2→ FFP Usu pt with upper GI bleeding **stent in liver to shunt blood away from portal vein into hepatic vein to bypass cirrhotic liver parenchyma; main complication→ encephalopathy and accumulation of toxic substances in the brain (ammonia) since liver isn’t acting as filter anymore Hemorrhoids Enlarged venous plexus Internal→ intermittent rectal Visual inspection Stage 1-2→ that INC with INC venous bleeding MC DRE ○ High fiber diet pressure: worse with ○ Hematochezia bright red blood Fecal occult blood testing ○ INC fluids pregnancy, defecation (esp per rectum (toilet paper/ toilet Proctosigmoidoscopy, ○ Warm sitz baths if constipated), prolonged water) colonoscopy in pts w/ ○ Bulk laxatives sitting, obesity ○ Vague anal discomfort hematochezia to r/o proximal ○ Topical rectal hydrocortisone r/o colon cancer ○ Rectal pain with internal sigmoid dz for pruritus and discomfort suggest complication Stage 4→ surgical if failed ○ Purple nodes if it prolapses consercative MGMT, ○ Uncomplicated internal are debilitating pain, strangulation neither palpable or tender ○ CI: Crohn’s dz ○ Stage 1→ confined to anal canal and may bleed w/ pooping ○ Stage 2→ protrude from anal opening but reduce spontaneously; bleeding and mucoid d/c may occur ○ Stage 3→ require manual reduction after bowel movement; may develop pain ○ Stage 4→ chronically protrude and risk strangulation External→ MC perianal pain, ○ aggravated with defecation, tender palpable mass; thrombosis may be precipitated by cough/ heavy lifting ○ visible peri-anally Hepatic Aggressive tumor that Screening: pt w/ cirrhosis: Image lesions 10.5 mg/L Stones, bones, abdominal groans, EKG🡪 Short QT, Prolonged PR IV Normal Saline and Furosemide Ionized fractional Ca+ > 5.6 mg/L psychic overtones INC PTH, DEC Phos Etiology CHIMPANZEES Ca+ supplement, hyperparathyroidism, Mets, Pagets, Addison’s, Zollinger Ellison syndrome, Excess vit D or vit A, Sarcoidosis HYPOMg+ Serum Mg 1.5-2.5 PE🡪 DEC deep tendon reflexes IV Calcium gluconate , Insulin plus Etiology (hyporeflexia) glucose , Dialysis (similar to TPN, Renal failure, IV over respiratory failure HYPERK+) supplementation CNS Depression HYPOPh+ Serum phosphate < 2.5 Weakness IV Phosphate replacement Etiology muscle and bone pain GI loses rickets, osteomalacia ETOH Abuse Poor pressor response, Sepsis cardiomyopathy renal loses HYPERPh+ Serum phosphate > 4.5 Asx Aluminum Hydroxide (binds to Etiology excess phosphate) Renal failure, sepsis, chemotherapy Hematologic Disease DVT’s Diagnosed in 20% of general surgical patients w/o prophylaxes Diagnosed 30% colorectal patients w/o prophylaxes TX ○ Compression Devices ○ SubQ Heparin or LMWH (Both equally effective at reducing DVT) ○ Low risk Pts🡪 Mechanical PPX with intermittent compression ○ Moderate risk pts🡪 LMWH or SQH or IPC ○ High Risk pts🡪 IPC + LMWH or SQH ○ Extended course (4 weeks)🡪 PTs undergoing Abdominal resection or pelvic malignancy Risk for PRX ○ Wound hematomas (MC Risk) ○ Mucosal bleeding ○ Reoperation Fluid/ Volume Disorders 1% of pts have reduced kidney function post-op ○ Reduce Risk: Push fluids Avoid NSAIDS Avoid IV contrast exposure Give pRBCs when needed before surgery in cases with hemorrhage or anema. Fluid Calculation ○ Maintenance fluids 40 + Pts weight in Kg Rule 4/2/1 Rule 4mL/kg for the first 10kg 2ml/kg for the next 10kg 1ml/kg for every kg over 20kg ○ Example: Calculate maintenance fluids for a 80kg women: 4ml/kg X 10 = 40 2ml/kg X10 = 20 1ml/kg X60 = 60 Total= 130ml/hr maintenance rate Quick: 40 + pts weight (kg) = Maintenance Rate for 24hrs Minimal Urine Output on maintenance fluids ○ 30ml/hr ○ Formula=.5cc/kg/hr Crystalloid Fluids ○ Normal Saline (NaCl) Na+: 154 mEq/L  Cl-: 77 mEq/L ○ Lactated Ringers Na+ : 130 mEq/L Cl-: 109 mEq/L K+: 4 mEq/L Lactate (Turns into bicarb so good for acidosis): 28 mEq/L Ca+: 2.7 mEq/L ○ D5W →5% Dextrose + ½ normal saline : Colloid Fluids ○ Albumin Dangerous to use🡪 Coagulopathy risk due to platelet deactivation. ○ Plasma Lyte Blood fluids ○ pRBC ○ FFP ○ Platelets ○ Whole blood Metabolic Disease Diabetes ○ Admission All patients must be assessed for diabetes on admission with blood glucose level. ○ Perioperative Hyperglycemia TX: IV short-acting insulin or SubQ sliding scale insulin. ○ Postoperative Hyperglycemia Risk: Wound infections, poor healing process, CVD (W> M), BG >140 is a major predictor for wound infection. TX: BG 90-100 🡪 IV insulin BG 120-200🡪 Moderate control Adrenal Insufficiency Pulmonary Disease MC Perioperative complication = PULMONARY Risk Factors ○ Operation: > 3-4 hours, Upper abdominal/ Open AAA repair, Open thoracotomy, previous pulmonary complications, asthma, age, bodyweight ○ Pre-existing lung conditions COPD ○ 1 week Pre-op🡪 Stop smoking (8weeks prior), prescribe antibiotics for purulent sputum, use of bronchodilators if needed. ○ Goal🡪 Get to best possible baseline Asthma ○ Elective surgeries🡪 Pt must be free of wheezing PEFR > 80% of predicted/ personal best prior to surgery. ○ Pts getting Intubated🡪 Administer beta agonist 2-4 puffs / Nebulizer treatment 30 minutes prior to intubation Pulmonary fibrosis/ restrictive lung dz: treat infx, remove sputum, stop smoking DX ○ Asthma and COPD and Pulm fibrosis🡪 PFTs Asthma PFT 🡪FEV1/FVC < 70% Reversible with bronchodilator COPD PFT🡪FEV1/FVC < 70% Irreversible with bronchodilator ○ Indications for PFTs prior to surgery (Spirometry with FEV) Exertional dyspnea, exercise tolerance, cough, productive sputum, hx of smoking, previous pulmonary complication, asthma, age, body weight ○ Non PFT indications Mild pulmonary compromise in pts undergoing non abdominal or thoracic surgery 🡪 Don’t need PFTs. ○ Increased risk PFTs🡪FEV1 < 50% ABG🡪 PaCO2 > 45 Treatment ○ Pre-Op Stop smoking, patient education, optimize underlying condition ABX for lower resp tract infx ○ Post-Op Incentive spirometry CPAP Early mobilization Substance Use Disorder Epidemiology ○ ETOH/Drug dependence 🡪 5-10% of the population (M>F) Methadone ○ Pts who are on methadone should be advised to continue the use of their methadone including on the day of surgery to avoid precipitating withdrawals. DX ○ All patients should be screened for ETOH and Drug abuse Risk Males > 2 drinks per day Females > 1 drink per day CAGE Need to cut down Annoyed by people criticizing your behaviors  Guilt about use Eye opener, need it right when you wake up in the morning ○ Labs Blood ETOH🡪 2 drinks = 0.08% (Legal limit) MCV, GGT, AST/ALT TX ○ Naltrexone (Narcan)🡪 Opioid antagonist used for overdose reversal. ○ Methadone (Opioid agonist @ mu receptor) Anesthesia Effects on substance abuse ○ Opioid abuse🡪 Predicting analgesic needs may be difficult ○ Sympathomimetic drug use🡪 Greater pressor response to stimuli like oro-tracheal intubation (cause blood vessels to contract) and may need more anesthetic. ○ PCA Pumps🡪 Patient controlled anesthesia: Usually morphine, avoid in patients with known drug abuse history Tobacco Use/ Dependence Epidemiology ○ 30% of patients undergoing general surgery smoke cigarettes ○ Every 1 in 5 people smoke Smoking within 1 year of surgery ○ Increases postop complications ○ Increase hospital cost ○ Higher use of resources ○ Decrease wound health ability Pre-op ○ Stop smoking at least 8 weeks prior to surgery If you stop < 8 weeks before surgery, you are at a higher risk of pulmonary complications d/t cough and sputum production Perioperative Benefits to short term smoking cessation Less vasoconstriction / irregular heart activity Decreased risk of blood clot Better wound healing Improved PFT’s Nicotine replacement therapy ○ Nicotine gum / Lozenge🡪 Helpful even on the morning of the surgery for a pre-op fast from cigarettes ○ NRT not necessary in hospital to treat withdrawals ○ Bupropion (Wellbutrin)🡪 Start 1-2 weeks prior to quitting Post operative Fever ( 6 W’s) ALL HAVE A FEVER* Intra Op ○ Wonder Drugs (Malignant Hyperthermia) Timing: Intra-Op DX/CM/Etiology: Malignant hyperthermia from drug RXN TX: Oxygen + Dantrolene + Cold IV Fluids PPX: Ask about previous anesthesia reactions Right after Surgery (Bacteremia) ○ Timing: Immediately after surgery ○ Etiology: Bowel perforation by surgeon ○ DX: Blood Cultures ○ TX: Broad ABX ○ PPX: Sterile field, careful technique POD #1 ○ Wind (Atelectasis) POD 1- POD 3 RF: Prolonged intubation, upper abdominal incision, lying supine, inadequate pain control. CM: Increased work of breathing, respiratory alkalosis, volume loss on CXR DX: CHEST XR: Distal lobar collapses on chest x ray TX: Incentive spirometry, chest physiotherapy, semi-recumbent position PPX: Get PT OOB, Incentive Spirometry POD #2 ○ Wind (Pneumonia) POD 2 (48hrs in hospital) RF: Unresolved atelectasis that results in pneumonia DX: CXR, Sputum CX TX: Broad spectrum abx PPX: Incentive spirometry, OOB POD # 3 ○ Water (UTI)🡪 Most Common ** (Also MC nosocomial infection) Timing: POD 3 Etiology: Urinary catheter DX: U/A, CX TX: Remove indwelling catheter + Empiric ABX therapy then modification on urine CX PPX: Get the FOLEY OUT EARLY*** ASAP POD #5 ○ Walking (DVT or Pulmonary embolism) POD 5- Pathogenesis: Can occur superficial or deep, DVT CM of PE: Tachycardia, tachypnea, pleuritic chest pain, EKG Right heart strain pattern, ABG hypoxia and hypocapnia DX: DVT Venography (Gold standard), Ultrasound (Initial). PE: CT Angio  TX: Heparin bridge warfarin* and IVC filter is 2nd line PPX: LMWH once back from surgery, OOB, SCD POD #7 ○ Wound (Cellulitis) Timing: POD5- 7 Organism: Staph most common CM: Red wound, tenderness, discharge, DX: U/S To rule out abscess Prevention: Sterile field in OR and when the pt goes home IV Zosyn POD # 10-14 ○ Whopper (Abscesses) Timing: 2+ weeks Cm: N/V wound erythema TX: Back to the OR: Percutaneous drainage / surgical debridement with ABX PPX: Keep wound clean Wound Infections Timing: 5-10 weeks after surgery CM: Fever (1st sign), Pain at incision site, Erythema, Drainage (Hardening of soft tissue), Induration, Warm skin. Dehiscence of wound🡪 Opening of the wound Pathogens: Staph (20%), E.coli (10%), Enterococcus (10%), Clostridium (Bronze/brown weeping tender skin) DX: CBC, Blood cultures, CT Scan to locate abscess, Wound culture TX: Remove any staples or sutures, Rule out fascial dehiscence, Pack open wounds, ABX Administration ○ Wounds that open🡪 Leave to heal by secondary intention Cardio INFO CM DX TX AAA Transmural inflammation of the aortic Back pain US (1st) Screening: males >65 and smoked→ US wall with apoptosis of smooth muscle Pulsatile abdominal mass ○ Further eval→ CT ABD SMOKING CESSATION * and degradation of elastin and HoTN Angiography = GS > 3 cm 🡪 Aneurysmal collagen leading progressing thinning +/- syncope 4.0-4.9cm🡪 Q annually and weakness of the aorta 5.0-5.4CM🡪 Q6 months Involves all three layers of the aorta > 5.5cm or >.5cm (5mm)expansion in 6 (Intima, media and adventitia) months 🡪 Surgical repair Risk factors BB Advanced age > 60 Smoking, Male sex, HTN History of atherosclerosis or CTD Aortic Dissection 2 layers involved (intima and media) Severe tearing/ ripping/ knife- CXR 1st→ wide mediastinum Lower The BP w/ RX Nitroprusside or BB like chest pain that radiates to Hemodynamically Unstable🡪 Type A 🡪 Includes Ascending Aorta 🡪 the back between the scapula Transesophageal echo (TEE) Surgical emergency ** Pulse variation between right Hemodynamically stable🡪 CTAngio Type B🡪 Does NOT include ascending and left arm aorta🡪 BB ** then Nitroprusside Arterial Embolism/ Etiology 6 Ps GS -Angiography Anticoagulation🡪 Heparin (IV Bolus Thrombosis Arterial occlusion (clotting/ stenosis) Pain, Pallor, Pulselessness, EKG followed by constant infusion) RF Paresthesia, Paralysis, Echo🡪 To look for clot in atria or Surgery embolectomy🡪 Cutdown with A-fib MCC of arterial occlusion from Poikilothermic ventricle, MI, Valve vegetation fogarty balloon (Catheter with balloon tip the heart that can be inflated with saline) or Mitral stenosis possible bypass if failed. Common femoral a. MC site of Post-Op Complication after Limb arterial occlusion by embolus Reperfusion therapy Lower extremity > Upper extremity Compartment syndrome Sources: Heart (85%), Aneurysms, Hyperkalemia Atherosclerotic plaques Renal failure from myoglobinuria MI Arterial/ Venous Ulcer Chronic defects of the skin that last Venous: Medial Malleolus ABI (Systolic ankle / Systolic arm)🡪 Below the knee compression socks 1st Disease longer than 4 weeks. Telangiectasis, reticular veins, Used to evaluate arterial blood line * Common location 🡪 Medial Malleolus varicose veins, brown-orange flow +/- Surgical debridement RF hyperpigmentation, Shallow, ABI 1-1.3 🡪 Normal Regular brisk walking for 30 minutes a Obesity, age, fhx chronic venous Irregular shape with well defined ABI 0.8-1.0 🡪 Mild PAD day insufficiency, hx of DVT. borders, stasis dermatitis, ABI < 0.8 🡪 Significant PAD Elevate extremity above heart atrophie blanche. ABI > 1.3🡪 Calcification of artery Non healing ulcers 🡪 Wound clinic  Arterial: Deep, dry wounds Imaging🡪 Duplex sonography affecting the toes and the Evaluate for diabetes dorsum of the foot. Abnormal Vasculitis suspicion🡪 Send biopsy distal pulses ABI is < 0.8 and cold Osteomyelitis🡪 Send tissue culture extremities. and bone scan > 4 weeks no heal🡪 Malignancy eval. Peripheral Artery MC is a consequence of Intermittent Claudication🡪 Foot Doppler ultrasound to measure ABI Rutherford Class Disease atherosclerosis and is a significant risk or leg pain that is improved ABI < 0.9 indicates PAD Type 1: Only when all senses are intact* factor for cardiovascular and when legs are dependent and ABI > 1.40 indicates non ○ Ischemia: Nonthreatening cerebrovascular morbidity and increased when legs are compressible arteries d/t ○ Sensory defect: None mortality. horizontal. calcifications. (Toe-brachial index is ○ Motor defect: None Etiology 6 P’s 🡪 Pain, pallor, paresthesia, further indicated🡪 TBI when describing chest pain. 1mm If severely symptomatic despite medical therapy and being considered for PCI Stable Transient ischemic chest pain that is Dull/vague chest pain, Radiation Coronary Angiography GS Beta Blockers Angina relieved with rest and exacerbated to the jaw or the arm, SOB, EKG with stress test shows ○ Decrease myocardial O2 Demand with exertion. Diaphoresis, anxiety, N/V. ST-Depressions ○ Decrease HR 🡪 Increase diastolic time🡪 Resolved with Rest and Nitrates Pharmacological stress test with Inc. coronary blood flow. Atypical CM: Epigastric pain in dobutamine Aspirin 81mg DM, Females, obesity and Elderly Nuclear stress test to find location ○ Reduce platelet aggregation at of the ischemia atherosclerotic plaque Nitrates PRN ○ C/I: Sildenafil, Inferior Wall MI, Hypotension Percutaneous Intervention (Stent Placement) ○ Definitive treatment ○ Must be placed on Plavix and ASA for stent thrombosis prevention * CABG ○ Indication: Left main obstruction or 3- vessel disease Prinzmeta Focal spasm of coronary arteries that Young patient experiencing Coronary Angiography 🡪 GS. Shows CCB l’s Angina causes a decrease in the coronary recurrent ACS symptoms that is transient coronary vasospasms ○ Diltiazem or Amlodipine vessel lumen size🡪Ventricular not associated with exertion definitive DX Nitrates PRN arrhythmias🡪 Myocardial ischemia 🡪 EKG🡪 Transient ST-Elevations that AVOID BB Myocardial infarction are not associated with a clot RF:  Smoking*, Cocaine use, hyperventilation, provocative agents (acetylcholine, ergonovine, arrhythmias serotonin) Nitric oxide deficiency🡪 A natural vasodilator, a deficiency of NO leads to vasospasm. Acute Unstable The stable acute plaque has become >30 min EKG= normal Antithrombotic Therapy : Coronary Angina exposed and the cap separates from NOT RELIEVED WITH REST OR Cardiac enzymes= normal ○ Aspirin 325 mg + Clopidogrel + Syndrome possible the high blood pressure or NITRATES Heparin exercise 🡪 Inflammation 🡪 Partial epigastric pain (Similar to Anti-Ischemic Therapy : Nitrates + BB+ blockage or complete blockage🡪 heartburn) Statin Troponin release🡪 Ischemia Recent exercise intolerance ○ Nitrates C/I: Inferior wall MI Acute plaque ruptures 🡪 prolonged SOB ○ BB C/I: Decompensated HF ischemia Diaphoresis N/V NSTEMI Acute plaque rupture 🡪 Small vessel Anxiety EKG: NO ST-Elevations Anti-Thrombotic: blockade 🡪 significant ischemia 🡪 Atypical Clinical Manifestations ○ Area of ischemia is not large ○ Aspirin 325 mg + Clopidogrel + Extremely elevated Troponin Epigastric Pain enough to cause ST Elevations. Heparin RF: Female, obesity, DM, fatigue, ○ ST-Depressions or T-Wave Anti-Ischemic Therapy : dizziness Inversions ○ Nitrates + BB+ Statin Complications →Endocardium infarction: ○ Nitrates C/I: Inferior wall MI Arrhythmias Deepest layer of the heart Eventually need reperfusion therapy MCC ventricular fibrillation Cardiac Enzymes : INC Troponins Inferior wall MI🡪 Bradycardia / Heart blocks STEMI Acute plaque rupture 🡪 Blockade of RCA Blockade leads SA node EKG: ST-Elevations Anti-Thrombotic: large vessel 🡪 Significant area of ischemia Transmural Infarction: All layers of ○ Aspirin 325 mg + Clopidogrel + ischemia 🡪 Extremely elevated Decompensated Heart Failure heart are ischemic Heparin Troponin Cardiogenic Shock Cardiac Enzymes : INC Troponins Anti-Ischemic Therapy : Hypotension due to decreased ○ Nitrates + BB+ Statin CO by the failing heart ○ Nitrates C/I: Inferior wall MI Ventricular Aneurysm Reperfusion Therapy: Posterior Wall MI 🡪 Ischemia to ○ Percutaneous Coronary Intervention apex of ventricle making it wide (PCI) within 90 Minutes and floppy ○ Thrombolytic Therapy: tPA, Papillary muscle infarction Streptokinase, Alteplase within 30 Leads to Mitral regurgitation Minutes Dyspnea Arrhythmi Etiology ECG, Event recorder, Holter on a A-Fib monitor, stress testing Exertion Inappropriate sinus tachy Sick sinus syndrome/ bradycardia HX Palpitations, syncope, dyspnea Myocardi Etiology Edema, JVD, S3 displaced apical ECG, BNP, Echo, stress test, al Cardiomyopathy, coronary ischemia impulse, murmur, crackles coronary angiography HX Dyspnea of exertion Paroxysmal nocturnal dyspnea Orthopnea Chest pain or tightness Prior coronary artery disease or afib Restrictiv Constrictive pericarditis, pericardial Paradoxical pulse EKG Showing low voltage QRS e effusion/tamponade along with electrical alternans HX Echo with increase pericardial fluid Chest pain, dyspnea XR Shows water bottle heart Valvular Aortic insufficiency/stenosis, Murmur, JVD ECHO congenital heart disease, mitral valve insufficiency/ stenosis HX Dyspnea on exertion Syncope Sudden, brief loss of consciousness Motionless, limp, cool EKG, Pulse Ox, Echo, Tilt table Determine underlying disease with loss of postural tone followed by extremities, weak pulses, shallow testing? spontaneous rival. breathing, muscle jerks Pathophysiology Near sympathy🡪 Light-headed, Insufficient cerebral blood flow sense of impending faint Etiology RED FLAGS: Vasovagal, idiopathic Syncope during exertion, multiple recurrences within a short period of time, a heart murmur or other findings suggesting structure heart disease, older age, significant injury during syncope, family hx of unexpected cardiac death. Varicose Veins Dilated superficial veins in lower Dilated, tortuous veins develop Clinical extremities; usually no obvious cause superficially in the lower Duplex Ultrasound  Risk factors extremity (Most commonly the Prior pregnancy, obesity, family great saphenous vein); May be history, prolonged sitting/standing, asx or aching/ fatigue; chronic history of phlebitis. distal edema, abnormal Etiology pigmentation, fibrosis, atrophy Valvular incompetence skin ulceration. Lipodermatosclerosis: Hardening of skin, skin color change, swelling and tapering of legs above the ankles d/t panniculitis (inflammation of fat layer) WPW: catheter ablation of bypass tracts: tx for pt w/ symptomatic arrhythmias (safer, cost-effective) Sick sinus syndrome: permanent pacemakers are the therapy of choice in patients with symptomatic bradyarrhythmias in SSS TX: pericardiocentesis MET Score: 1 MET=3.5mL oxygen uptake MET 1: Can take care of herself MET 3-4: Can walk up a flight of stairs MET 4-10: Can do heavy work around the house MET > 10: Participate in sports Endo INFO CM DX TX Adrenal Rare 24 hr catecholamines Complete adrenalectomy Carcinoma Benign masses: MRI or CT of abdomen to visualize Pre-op non-selective alpha (ACC) ○ Myelolipoma catecholamine secreting tumor blockade ○ Lipoma ○ Phenoxybenzamine or ○ Pseudocysts phentolamine Functional tumors ○ Hyperaldosteronism: Conn Syndrome ○ Cortisol- Producing adenomas ○ Pheochromocytoma Hyper- INC aldosterone production by the adrenal glands. HYPOK+ + HTN Primary Hyperaldosteronism Adrenal Adenoma→ aldosteronism Aldosterone’s function is to reabsorb Na+ and ○ HTN: D/t INC renal reabsorption ○ HIGH Aldosterone, LOW RENIN Adrenalectomy excrete K+. Reabsorption of Na+ leads to INC BP of Na+ (and water will follow)- Secondary Hyperaldosteronism Bilateral Adrenal hyperplasia → Etiology WILL NOT RESOLVE WITH MEDS ○ HIGH Aldosterone, HIGH RENIN Spironolactone CONN Primary hyperaldosteronism / Conn’s Syndrome ○ HYPOK+: Na+ is being ○ Imaging: Renal Doppler US ○ Blocks aldosterone receptor syndrome ○ Autonomous production of aldosterone in the reabsorbed so K+ is being Saline Infusion Test (Na+ Renal Artery Stenosis --> absence of RENIN stimulation d/t: excreted Overloading) GS ○ ACE Inhibitor or ARB: The ○ Bilateral adrenal hyperplasia or Adrenal Metabolic Alkalosis: K+ being ○ It should DEC aldosterone levels problem is the stimulation of the  Adenoma excreted from cell so H+ atoms but it does not RAAS system so if you block Secondary Hyperaldosteronism will drive into the cell RAAS then you block ○ Excessive RENIN stimulation on the adrenal aldosterone’s effects glands d/t: ○ Renal Artery Angioplasty ○ Renal artery stenosis Definitive treatment ○ Atherosclerosis: 70 y/o man with atherosclerosis ○ Fibromuscular dysplasia : 30 year old female Cushing’s INC in serum cortisol levels d/t either pituitary Catabolic Syndrome “Low then High” Adrenal Adenoma🡪 Resect the Syndrome adrenal, adrenal adenomas, bilateral adrenal ○ Hyperglycemia + HTN + Step 1: Low-Dose dexamethasone cortisol secreting adenoma hyperplasia. Osteoporosis Suppression Test + 24 Hr urine Exogenous steroid use 🡪 Stop the Etiology Body Habitus Changes test glucocorticoids ACTH Dependent🡪Over secretion of ACTH Levels ○ Central obesity ○ If you give someone dexa→work Pituitary adenoma🡪 Resect (TSS- ○ Cushing DISEASE: Cause by a pituitary adenoma: ○ Buffalo hump and Moon facies similar to cortisol→ goes to the transsphenoidal surgery) Excess ACTH secretion ○ Striae : Purple scars hypothalamus and blocks Small cell carcinoma🡪 ○ Small cell bronchogenic carcinoma: Lung tumor ○ Hirsutism, Acne, Thin Skin secretion of CRH →blocks ACTH Chemotherapy secreting ACTH Impaired immunity secretion from ant. Pituitary → ○ High ACTH and High Cortisol Macroadenoma 🡪 Pituitary DEC ACTH and Cortisol. ACTH Independent🡪 Low ACTH levels d/t High adenoma causing headache and ○ Cushing’s syndrome: High Cortisol Levels visual deficits Cortisol + High ACTH ○ Exogenous glucocorticoids: MCC of Cushing’s ○ SOMETHING either an syndrome adenoma, adrenal or cancer ○ Pt is taking too many steroids so their body will tumor is secreting ACTH still. over exert the natural effects of cortisol, stop the ○ RULE OUT ANY MEDICATION steroid slowly to avoid adrenal crisis and prevent USAGE AND THEN MOVE ON dangerously low cortisol levels. Step 2: ACTH Levels ○ Adrenal Adenomas: Leading to excess cortisol ○ Adrenal Tumor/ Hyperplasia: secretion Low ACTH, High cortisol🡪 Stop ○ Bilateral adrenal hyperplasia: Leading to excess this is diagnosis cortisol secretion ○ Pituitary Adenoma OR Small ○ LOW ACTH and High Cortisol cell carcinoma: High ACTH & High Cortisol Step 3 High- Dose dexamethasone suppression test ○ Pituitary Adenoma: If you give high dexa then it should cause the ant pituitary to suppress at least a little bit and stop secreting ACTH. →Result: Low ACTH & Low Cortisol ○ Neuroendocrine Tumor →Result: High ACTH and High Cortisol Pheochromocyt Catecholamine secreting adrenal tumor that Classic triad: Episodic headaches Plasma metanephrines (high Alpha-blockers first, followed by oma secretes NE and EPI leading to HTN, Palpitations, (80%), diaphoresis (70%) and sensitivity) and fractionated volume expansion and (if needed) HA, sweating palpitations (60%) catecholamines (less useful) beta-blockers Over 90% are benign Hypertension (90%), syncope, 24 hr urine metanephrines (urine) (Phenoxybenzamine) pallor (NOT FLUSHING), panic (high specificity), VMA and/or →AVOID BB as INITIAL therapy!!! attacks, abdominal pain catecholamines (remember β2 receptors vasoD; Looks like anxiety, Adrenal CT or MRI, MIBG scan, Ga blockade causes unopposed hyperthyroidism, hypoglycemia, 68 DOTA alpha-mediated vasoC) migraines Surgical excision Some have malignant potential thus need lifelong surveillance if high risk Adrenal Crisis MCC Acute worsening adrenal insufficiency d/t Shock → HoTN w/ organ Random cortisol Hydrocortisone 100 mg IV every 8 abrupt withdrawal of glucocorticoids ischemia +/- cosyntropin stimulation testing hours ○ MUST TAPPER PATIENTS off who are chronic HYPOglycemia Supportive treatment, IVF steroid users HYPOnatremia Treat underlying illness Stressful Event Abd pain & emesis Trauma, infection, dehydration Orthostatic HoTN Fever HYPER- INC in serum TH and a DEC or absence of TSH. HEAT intolerance PE Indications for surgical TX thyroidism Etiology Nervousness, tremor, weight loss, Goiter, tachycardia, afib, warm ○ Very large goiter Grave dz🡪 Auto antibodies made to mimic TSH and increase appetite, heat moist skin, thyroid thrill/bruit ○ Low RAI uptake bind to TSH receptor, triggering T3/T4 secretion intolerance, sweating, muscular Exophthalmos’s 🡪 Graves disease ○ Malignancy suspicion Toxic multinodular goiter🡪 Hyperplasia of thyroid weakness/fatigue, increased Labs ○ Ophthalmopathy follicular cells, Independent from stimulation, its bowel frequency, polyuria, LOW/Absent TSH, INC T3/T4 ○ Amiodarone induced believed to be a mutated receptor. menstrual irregularities, infertility Radioactive iodine uptake hyperthyroidism Thyroiditis 🡪 Infectious or drug-induced Palpitations, Arrhythmias🡪 T3/T4 High ○ Females desiring to get INC vasoC and tachycardia ○ Diffuse uptake🡪 Graves pregnant within a year of Osteoporosis🡪 T3/T4 stimulates ○ Nodular uptake🡪 Toxic treatment bone reabsorption adenoma or multinodular IV FLUIDS/ cooling blankets🡪COOL Thyroid Tremor goiter THEM DOWN ○ High frequency, low amplitude Low Beta-blocker🡪 Propranolol and is present with action. ○ High serum thyroglobulin Thioamides: PTU or methimazole ○ Patho: from a heightened 🡪Thyroiditis Steroids🡪 Block conversion of T4 beta-adrenergic state which is ○ Low🡪 Exogenous thyroid to T3 why propranolol is most hormone indicated for treatment. Thyroid Storm SEVERE hyperthyroidism that leads to a state of HEAT intolerance Cool them down with cool IV SHOCK Afib fluids and Cooling blankets Severe dehydration Propranolol Severe fever Thioamides: IV PTU or HTN Methimazole AMS HYPO- DEC serum thyroid hormone levels, MC d/t intrinsic COLD intolerance PRIMARY: Levothyroxine (T4) → converts to thyroidism thyroid dysfunction. Primarily hypothyroidism Everything slows down ○ high TSH T3 in the periphery Etiology Fatigue ○ low free T4 & T3 →a T4 replacement Hashimoto’s thyroiditis: MCC in US ○ Hair loss SECONDARY: →No proven benefit to adding T3, Iatrogenic: Thyroidectomy or Radio-iodine therapy ○ Constipation ○ low/high/normal TSH because T4 will be converted Iodine Deficiency or Iodine Excess: MCC of ○ Heavy period ○ low free T4 & T3 anyway hypothyroid world wide ○ Depression SUBCLINICAL: →Long t1/2 of 7 days ○ Iodine Deficiency: Can't make T3/T4 ○ Muscle weakness ○ high TSH →Missing one dose has no effect ○ Iodine Excess: Inhibits iodine organification and ○ Decreased libido ○ normal free T4 & T3 →Start at a lower dose and INC then inhibits T3/T4 synthesis ○ Muscle aches, tenderness and gradually in older patients, those →Blocked blocks iodine organification stiffness pts with CVD (b/c heart may not Cretinism in children→ LOW T3/T4 ○ LE edema, angioedema have the function to work as hard) Hypothyroidism during rapid development. can (accumulation of subcutaneous Tx monitored by checking TSH, impair growth and development tissue →accumulation of water) goal ~2 common:1/4000 newborns; but oftentimes Bradycardia →goal might be lower after surgery recognized early and treated d/t neonatal screening Puffy face (connective tissue for thyroid cancer molecules acculuares and don’t Check TSH 4-6 wks (wait 5 breakdown as they should → half-lives; needed to reach new accumulates water) same can plateau) after any dose change occur in vocal cords → hoarse Dose change can happen for voice various reasons: Pale, dry, yellowish skin →Need less thyroid hormone as Coarse, dry hair you age (esp over the course of Enlarged tongue decades) Low body temperature, etc. →Unexplained fluctuations Severe hypothyroidism or over a Always ask patient how they are long time → “Myxedema coma” taking their meds Hashimotos Autoimmune disorder: Production of antibodies Weight GAIN and cold intolerance + Thyroid peroxidase antibodies or against thyroid tissue and enzymes (EX: Thyroid Myxedema: Generalized + Thyroglobulin Peroxidase) --> Destruction and fibrosis of the non-pitting edema High TSH, Low T3/T4 thyroid--> Hypothyroidism ○ Medical Emergency Anti-TPO ** ○ SEVERE hypothyroidism leading to: →Decreased mental status →Hypothermia →Slowing if organs: myxedema Diastolic HTN Constipation HDL Depression Amenorrhea Pituitary Tumor DEC TSH🡪 Cold intolerance, weight gain, fatigue DEC ACTH🡪 DEC cortisol l/t fatigue, slow return to health after minor illness and orthostatic hypotension. Hyper- Primary🡪 Eti: Parathyroid adenoma N/v, loss of appetite, weakness, Ultrasound Symptomatic🡪 Surgically Remove parathyroidism MEN 1: PPP fatigue, constipation, confused, Labs: INC Ca, INC PTH, DEC Serum the adenoma in ALL symptomatic ○ Parathyroid carcinoma lethargic, polyuria with renal Phos patie