1 CARDIOLOGY Aortic Aneurysm -Occurs when blood collects between the aortic ves

1 CARDIOLOGY Aortic Aneurysm -Occurs when blood collects between the aortic vessel layers, with true aneurysms involving all 3 layers (intima, media, adventitia) -Most commonly occurs below the kidney Risk Factors -Smoking -HTN -Hyperlipidemia -Male -Atherosclerosis -FH Differential -Pseudoaneurysm: a collection of blood and connective tissue located outside of the vessel wall Prognosis -Can spontaneously rupture -Post-op complications: MI, reduced blood flow to LEs from emboli, AKI, mesenteric or spinal cord ischemia, device migration or endoleak with graft placement Abdominal Aortic Aneurysm Thoracic Aortic Aneurysm -Normally AA is 2 cm, becomes aneurysmal when > 3 cm -Caused by atherosclerosis and inflammation -Categorized based on morphology -Usually infrarenal in location Screening -USPSTF recommends US screen in all men 65-75 who have ever smoked -May also want to screen women with cardio risk factors and anyone > 50 with a FH Signs & Symptoms -Usually asymptomatic and discovered incidentally on abdominal exam -Abdominal or back pain -May have signs of limb ischemia Workup -Abdominal US for diagnosis -Abdominal CT for further characterization and measurement Management -Surgical repair indicated when > 5 cm; may be endovascular (stent) or open graft repair; endovascular has lower short-term mortality/morbidity but open repairs have better long-term outcome -Watchful reimaging and risk reduction if < 5 cm: smoking cessation -Consider elective nonrepair and cessation of surveillance imaging if life expectancy is < 2 years -Further classified as ascending, descending, or arch -Ascending thoracic AA usually due to elastin degradation, which can be normal aging or accelerated by HTN, connective tissue disorder, RA, or bicuspid aortic valve -Descending thoracic aneurysm is caused by atherosclerosis -Arch aneurysm seen in trauma or deceleration injuries Signs & Symptoms -Aortic insufficiency symptoms from dilation of valve -CHF -Compression of SVC by enlarging aorta Æ SVC syndrome -Tracheal deviation -Cough -Hemoptysis -Dysphagia -Hoarseness -Steady, deep, severe substernal, back, or neck pain Workup -CXR for widened mediastinum, enlarged aortic knob, tracheal displacement -MRI or CTA are test of choice for characterization and dx -Echo Management -BP conWUROȕ-blockers preferred -Re-image with CT or MRI every 6 mos -Surgical management is risky and complicated = rarely done, need to weigh risk of rupture -Surgical repair indicated for thoracic $$•6 cm, rapid expansion of aneurysm, or symptomatic aneurysm Prognosis -Less likely to spontaneously rupture than AAA Varicose Veins -Usually occur in the saphenous veins Causes -Incompetent valves from damage or venous dilation -AV fistula -Congenital venous malformations Signs & Symptoms -Dull or aching pain in legs that is worse after standing -Pruritus -May have h/o DVT -Brownish thinning of the skin above the ankles Differential -Claudication -Superficial thrombophlebitis -Arthritis -Peripheral neuropathy Management -Compression stockings -Leg elevation -Venous ablation -Sclerotherapy -Great saphenous vein stripping Prognosis -Complication of thrombophlebitis 2 Aortic Dissection -Occurs when tear in the inner wall of the aorta causes blood to flow between the wall layers Æ creation of false lumen -Acute or chronic -Usually in ascending aorta -Typically in men 60-70 -Debakey and Stanford classifications Risk Factors -Connective tissue disorders -Bicuspid aortic valve -Coarctation of the aorta -HTN Causes -Usually a result of HTN -Increased risk in pregnancy, connective tissue disease, bicuspid aortic valve, aortic coarctation Signs & Symptoms -Sudden onset of “ripping” retrosternal and back pain -HTN -Hypovolemia -Syncope -Shock -Pulse discrepancies -Cardiac tamponade -May have focal neuro deficits or CVA due to poor perfusion of the brain Workup -EKG may show infarct pattern or LVH -CXR will show widened mediastinum, L sided pleural effusion -Bedside TEE test of choice, CT if unavailable Management -Achieve hypotension and EUDG\FDUGLDZLWKȕ-blocker and nitroprusside -Surgical repair for Stanford type A -Stanford type B admitted to ICU for medical management: PRUSKLQHIRUSDLQFRQWUROȕ- blockers and nitroprusside Prognosis -Greater than 20% intra-op mortality -50% mortality within 10 years of all hospital survivors Deep Venous Thrombosis Signs & Symptoms -Palpable cord -Calf pain -Ipsilateral edema, warmth, tenderness, erythema Workup -Homan’s is only + 50% of the time -Determine probability with Well’s criteria Æ < 2 indicates unlikely, > 6 highly likely -Further investigation using D-dimer -US for at least moderate Well’s score Management -Immediate anticoagulation with heparin, LMWH, or fondaparinux -Lytics or thrombectomy for select cases -3 months of anticoagulation for initial distal DVT or consider IVC filter if not a good candidate 3 Coronary Artery Disease -Risk of developing CAD for 40 year olds in the US is 49% for men and 32% for women -Risk factors: age, males, FH, sedentary lifestyle, tobacco+71'0ĹOLSLGV Classification -Class I = no limitations or symptoms with normal activity -Class II = slight limitations and normal activity results in symptoms -Class III = marked limitation and minimal activity results in symptoms -Class IV = symptoms persist with minimal activity and rest Screening -Consider stress test in asymptomatic pts with multiple risk factors Signs & Symptoms -Angina -SOB -Sudden cardiac death is the first symptom in 15% Chest pain differential -Atherosclerosis -Vasospasm from cocaine or stimulants -Prinzmetal’s angina: women under 50 -Coronary artery or aortic dissection -Congenital abnormality -Aortic stenosis -HCM -Coronary thrombus or embolus -Non-cardiac: costochondritis (reproducible on palpation), intercostal shingles, cervical or thoracic spine disease (reproducible with specific movements of the head or neck, causes paresthesias), PUD, GERD, cholecystitis, PE, pneumonia, pneumothorax (dyspnea) Workup -PE findings: S4, arterial bruits, abnormal funduscopic exam, corneal arcus, xanthelasma, tendinous xanthoma, CHF, murmurs -EKG -Refer for stress test if pt has low to intermediate probability of CAD -Refer for cardiac cath if pt has high probability of CAD Management of new disease or worsening symptoms -Referral to cardiology -ER via ambulance if EKG shows new ischemic changes: ST depression or elevation, inverted T waves or there is hemodynamic instability Management of stable disease -LDL goal <100 or <70 -ȕ-blocker (proven mortality benefit), CCB, statin, clopidogrel, nitrates PRN -New drug ranolazine for refractory chest pain -PCP visits every 6 months: annual CBC to check for anemia, annual lipids, FBG -Cardiologist every 1-2 years -Consider early revascularization for significant narrowing of LAD, left main CAD, LVEF < 30%, or large area of myocardium at risk PULMONOLOGY Acute Respiratory Distress Syndrome (ARDS) -Noncardiogenic pulmonary edema caused by capillary leaking from infection or inflammation Æ parenchymal inflammation and edema Æ impaired gas exchange and systemic release of inflammatory mediators Æ further inflammation, hypoxemia, and frequently multiple organ failure Acute lung injury (ALI) = a less severe form of ARDS Inciting Events -Pneumonia of any kind -Chemical inhalation -Chest trauma -Sepsis -Pancreatitis -Connective tissue disease: lupus -Vasculitis -Hypersensitivity rxn to blood transfusion -Burns Stages -Stage I: clear CXR, infiltration of PMNs begins -Stage II: develops over 1-2 days with patchiness on CXR with edema and type I alveolar cell damage -Stage III: develops over 2-10 days with diffuse infiltration on CXR, exudates, proliferation of type II alveolar cells functioning as repair cells -Stage IV: develops > 10 days with diffuse infiltration on CXR, involvement of lymphocytes Æ pulmonary fibrosis Workup Diagnostic criteria: known clinical insult < 1 week ago, bilateral opacities consistent with pulmonary edema on CXR or CT, not explained by cardiac failure or fluid overload, hypoxemia present on minimal ventilator settings (PaO2/FiO2 < 300) Management -Treat underlying cause! -Usually mechanical ventilation is needed, using low tidal volumes and PEEP -Use of steroids is controversial -Supportive care: sedatives, nutritional support, BG control, DVT prophylaxis, GI prophylaxis, neuromuscular blockade for vent G\VV\QFKURQ\WRĻ2GHPDQGNHHSIOXLGEDODQFHHYHQWRQHJDWLYH Prognosis -Overall mortality 40-60% 4 Lung Cancer (Bronchogenic Carcinoma) -85% of cases occur among smokers -Other contributing causes include radon gas, asbestos, and environmental pollutants -2 major groups (small cell and non-small cell) account for 95% of lung cancers -Other lung cancers are rarer and include primary pulmonary lymphoma, carcinoid tumors, bronchoalveolar cancers, and mesotheliomas -Overall survival rate of 14% Signs & symptoms -Lung cancers are more like to cause paraneoplastic syndromes such as hypercalcemia, SIADH, ectopic ACTH secretion, Lambert-Eaton myasthenic syndrome, and hypercoagulable states -Nonspecific cough or dyspnea -Chest pain -Hemoptysis -Anorexia, weight loss, fevers, night sweats -Hoarseness due to compression of the recurrent laryngeal nerve -Facial or UE swelling from SVC syndrome -Bone, brain, liver, or adrenal symptoms from mets -Axillary or supraclavicular adenopathy -Digital clubbing Differential -TB -Fungal infection -Mets to the lung -Sarcoidosis Workup -Begin with CXR -F/u masses with CT -Sputum cytology -Bronchoscopy -Transthoracic needle biopsy -Node sampling via transbronchial biopsy, mediastinoscopy, or mediastinotomy Management -Assess feasibility of surgical resection and overall patient health/quality of life issues -Radiation for advanced disease or nonsurgical candidates -Combination chemotherapy for candidates -Monitoring for recurrence Non-Small Cell Carcinoma Small Cell Carcinoma Bronchial Carcinoid Tumor Squamous Cell Carcinoma Adenocarcinoma -Arises as discrete masses within the lung parenchyma that can spread to regional lymph nodes and then metastasize to distant sites -Squamous, adeno, and large cell carcinomas -Staged by TNM -Limited response to chemo -Surgical resection of limited tumors can be curative -Metastasize rapidly to regional lymph nodes and distant sites -Classified as limited or extensive disease -Very responsive to chemo -Remission is common but so is recurrence Æ overall survival of 5% -Previously known as bronchial adenoma -Rare group of pulmonary neoplasms characterized by neuroendocrine differentiation and relatively indolent clinical course -Can also uploads/Management/ surgery-study-guide.pdf

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• Détails
• Publié le Mar 30, 2022
• Catégorie Management
• Langue French
• Taille du fichier 1.7224MB