Perioperative medical care:
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished

44 yo WF who presented to ER today with RUQ three days ago.  RUQ U/S showed gallstones.  CT scan of the abdomen/pelvis showed gallstones.
Pre-op this patient”
History and physical
Informed consent for operation and blood
Type and screen or type and cross
CXR (age greater than 20)
12-lead ECG (age greater than 40)
BMP, M/P, CBC, PT, PTT, INR
Nill per Oral after MN (IV Fluids)
Pre-op Note
Pre-op Orders (hep 5000 units SQ, Abx, beta blocker)
?Bowel Prep

Chest Pain Work Up
Coronary Artery Disease
Physiology of surgery:
 myocardial oxygen demand
 catecholamines:  HR,  contractility, PVR
 HR also causes decreased diastolic filling
Coronary arteries fill in diastole
Less blood flowing in coronaries: less myocardial O2 supply

Myocardial Infarction
Pt without risks has 0.5% chance of MI
Pt with risks has 5% chance of perioperative MI
Perioperative MI has 17-41% mortality
CAD causes MI....look at PMH

Prevention of perioperative cardiac events
Wait 6 months if possible
Beta-blockade*
200 pts with CAD or risk factors for CAD
atenolol pre-op and peri-op in ½
MI reduced 50% in first 48h
2 year mortality 10% vs 21%
Maintain peri-operative normothermia
 cardiac events, esp. arrhythmias
Treat peri-operative hypertension


Fibrocystic Breast Disease

Posted by e-Medical PPT

Fibrocystic Breast Disease (FBD)
Most benign breast condition
Incidence-varying, related to age
Menstruating years-20%
30-50% in premenopausal years
Synonyms- Mammary dysplasia,  Cystic disease, Cyclic Mastopathy, Cystic Hyperplasia

Pathophysiology
Hormonal basis
Oestrogen & Progesterone
Oestrogen predominance over progesterone is considered causative
Serum levels  of Oestrogen >
Luteal phase is shortened
Progesterone level decreased to 1/3 normal
Corp. Lut. Deficiency / Anovulation in 70%
Patients with Pre Menstrual Tension syndrome  more likely to develop  FBD
Women with progesterone deficiency carry a five fold risk of premenopausal breast cancer

Prolactin-
levels are increased in 1/3 of women with FDB
Probably due to Oestrogen dominance on pituitary
Thyroid –
Suboptimal levels sensitize mammary epithelium to Prolactin stimulation
Methylexanthiones-
Increased intake of coffee, tea, cold drinks chocolate is associated with development of FDP

Trauma- NOT A CAUSE

Oestrogens stimulate proliferation of connective and epithelial tissues.' The polymorphism of fibroeystic disease is documented by fibrosis, cyst formation, epithelial proliferation, and lobular-alveolar atrophy. FBD entails simultaneous progressive and regressive change. Ductular branching, intraductal epithelial proliferation(papillomatosis), lobular hyperplasia, and proliferation of intralobular connective tissue may undergo regressive       changes       such       as. adenofibrosis, srlerosing adenosis, duct dilation, cyst formation, and calcification. Loss of parenchymal elements (ductules, alveoli) with intra-lobular and periductal fibrosis is encountered in chronic disease..


Dysmenorrhoea
Defined as painful menstruation.
 Although  some pain during period is normal, pain that is sever enough to limit normal activity or requires medication is abnormal and requires evaluation.
Affects about 50% of menstruating women and regarded as sever in 10%  of sufferers
Dysmenorrhoea is the leading cause  for absence from school or work

Primary dysmenorrhoea: occurs in otherwise healthy women with no organic cause
Secondary dysmenorrhoea: due to an underlying disease or structural uterine abnormality
Causes :
endometriosis
adenomyosis
chronic pelvic inflammatory disease
Pelvic congestion syndrome
pelvic adhesions
IUD
fibroids

Dyspareunia
Defined as pain during or after intercourse
It is not a disease ,but rather a symptom of an underlying physical or psychological disorder 
Could be superficial at entrance of the vagina or  deep in the pelvis on deep penetration

Superficial dyspareunia:
Vaginismus
Vaginal infection
Episiotomy scars & narrowed vagina
Insufficient vaginal lubrication
Atrophic vagina due to menopause

Premenstrual Syndrome
Distressing physical, psychological and behavioural symptoms, not caused by organic disease, which regularly recur during the same phase of the menstrual (ovarian) cycle and which significantly regress or disappear during the remainder of the cycle
Affects 30-40% of women of child bearing age but in 10% the symptoms are so sever and disabling (premenstrual Dysphoric dysorders (PMDD)
Over 150 symptoms have been documented but the three most prominent are , irritability, tension & dysphoria (unhappiness)


Brain Death

Posted by e-Medical PPT

Cardiac death:
 Heartbeat and breathing stop
Brain death:
 Irreversible cessation of all functions of the entire brain, including the brain stem

Coma
Deep coma
Non-responsive to most external stimuli
At most, such patients may have a dysfunctional cerebrum but, by virtue of the brain stem remaining intact, are capable of spontaneous breathing and heartbeat
PVS – persistent vegetative state

Basic examination
Cerebral motor response to pain
 Supra-orbital ridge, the nail beds, trapezius
 Motor responses may occur spontaneously during apnea testing (spinal reflexes)
 Spinal reflex responses occur more often in young
 If pt had NMB, then test w/ train-of-four
Spinal arcs are intact

Pupils
Round, oval, or irregularly shaped
Midsize (4-6 mm), but may be totally dilated
Absent pupillary light reflex
Although drugs can influence pupillary size, the light reflex remains intact only in the absence of brain death
IV atropine does not markedly affect response
Paralytics do not affect pupillary size
Topical administration of drugs and eye trauma may influence pupillary size and reactivity
Pre-existing ocular anatomic abnormalities may also confound pupillary assessment in brain death

Oculocephalic reflex
Rapidly turn the head 90° on both sides
Normal response = deviation of the eyes to the opposite side of head turning
Brain death = oculocephalic reflexes are absent (no Doll’s eyes) = no eye movement in response to head movement..


Introduction
What is Lyme Disease
How is "Lyme Disease" Contracted
How prevalent is "Lyme Disease"
What are the co-infections and co-morbid conditions
What are the symptoms of "Lyme Disease"
How is "Lyme Disease" diagnosed
How is "Lyme Disease" treated

Traditionally, Lyme disease is defined as an infectious illness caused by the spirochete, Borrelia burgdorferi
This is technically correct; clinically the illness is much more than that, especially in the disseminated and chronic forms.
This includes infection not only from B. burgdorferi, but the many co-infections that may also result.
Furthermore, in the chronic form of Lyme, other factors can take on an ever more significant role; immune dysfunction, opportunistic infections, co-infections, biological toxins, metabolic and hormonal imbalances.

Erythema Migrans; Pathognomonic for Borreliosis; 'rash' only occurs in 40-60% of people who are bitten and contract Borrelia spp.
Early localized: single EM or rash with no constitutional symptoms.  Treat promptly and aggressively referring to ILADS or IDSA guidelines.
Early Disseminated disease: multiple lesions, constitutional symptoms, lymphadenopathy, or any other manifestations of dissemination that are 'mild' and present for less than one year, are not complicated by immune deficiency or prior steroid treatment.  Refer to a "Lyme Literate Physician.”
Late Disseminated disease: Symptoms present for more than one year, more severely ill patients, and those with prior significant steroid therapy or impaired immunity secondary to lyme disease or any other reason.  REFER to lyme literate physician and co-manage with their direction.

Symptoms in Lyme Disease
Every organ & organ system can be affected  This is a list of some of the LD symptoms by body system and is not an exhaustive compilation of possible symptoms
Neuro: headaches, facial paralysis, seizures, meningitis, stiff neck, burning, tingling or prickly sensations (parathesia), loss of reflexes, or possible increased or normal reflexes with slow return, loss of coordination and equilibrium.
Neuropsych: mood swings, irritability, anxiety, rage ("Lyme Rage"), poor concentration, cognitive loss, memory loss, loss of appetite, mental deterioration, depression, disorientation, insomnia and numerous mood and psychiatric disorders that were not present prior to lyme disease or are extremely exacerbated by lyme disease...

Diagnosis
ILADS Guidelines: based on clinical diagnosis via a scoring method. Points are added up based on exposure/possible exposure, EM, symptoms consistent with lyme, and labs are tallied.  7 or above is highly likely Lyme.  5-6 is possible, and 4 and below is unlikely...

Pancreatic Pseudocysts

Posted by e-Medical PPT

Localized collection pancreatic secretions
Within or adjacent to pancreas
Enclosed by a nonepithelialized wall
Associated w/ pancreatic duct disruption

Etiology
Acute Pancreatitis
More associated w/ alcohol related pancreatitis
Chronic pancreatitis
Pancreatic trauma
Pancreatic neoplasm

Pathogenesis
Acute Pancreatitis
Pancreatic necrosis causes ductular disruption, resulting in leakage of pancreatic juice from inflamed area of gland, accumulates in space adjacent to pancreas
Inflammatory response induces formation of distinct cyst wall composed of granulation tissue, organizes w/ connective tissue and fibrosis

Chronic Pancreatitis   
Pancreatic duct chronically obstructed  ongoing proximal pancreatic secretion leads to saccular dilation of duct – true retention cyst
Formed microcysts can eventually coalesce and lose epithelial lining as enlarge

Symptoms and Signs
Insidious midepigastrium pain, radiation to back
Pain aggravated by food
n/v, abdominal fullness
Small to moderate cysts can be assymptomatic
Palpable mass in epigstrium if large
Jaundice only in 10%
Also may have pleural effusion, chylous ascites, portal hypertension..

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