Case 5: Matilda Nagao Flashcards
DDx Right Upper Quadrant Abdominal Pain
- Acute cholecystitis: acute inflammation of the gallbladder (+ Murphy’s sign, presence of gallstones, increased bilirubin/AST/ALT)
- Cholangitis: Biliary obstruction w/ infection (Charcot triad-RUQ pain, jaundice, fever)
- Liver abscess (Nausea/vomiting, hepatomegaly)
- Small bowel obstruction (constipation, dehydration, abdomen distention, decreased bowel sounds)
- Peptic ulcer disease (gnawing pain releived by food/liquid antacids)
- Hepatitis C: (malaise, jaundice, pruritis, rash)
Risk factors for acute cholecystitis
Gallstones
Hemolytic disease
Oral contraceptives
Alcoholic liver disease
Obesity
Rapid weight loss
Native American
Signs/Symptoms of acute cholecystitis
RUQ pain
+ Murphy’s sign (stop inspiration upon palpation)
Palpable gallbladder
Fever
Nausea/vomiting
Pain onset following fatty meals
Diagnosis of acute cholecystitis
Gallbladder ultrasound (gold standard)
HIDA scan (look for absence of gallbladder filling within 60 min after administration suggests cystic duct obstruction)
Leukocytosis
Increase ALT, AST, bilirubin, and alkaline phosphatase levels
Treatment of acute cholecystitis
Prevent further ingestion of food
Laparascopic cholecystectomy (gold standard)
Open cholescystectomy
High risk patients undergo IV fluids and antibiotics
What are the 2 major types of gallstones and how do they differ in
Frequency?
Description?
Composition?
Cholesterol stones
- 80% of gallstones (more common)
- Pale yellow, round-ovoid, hard external surface
- Crystalline cholesterol monohydrate
Pigment stones
- 20% of gallstones
- Black (Radiopaque, hemolysis-related) or brown (radiolucent, spongy, infection-related)
- Bilirubin + Ca salts
What are the conditions that favor gallstone formation?
- Supersaturation of bile with cholesterol
- Obesity can cause hyperinsulinism, increase HMG CoA reductase activity, increase cholesterol synthesis in liver
- Decreased bile salt synthesis
- Hypomotility of gallbladder
- Medication, surgery, pregnancy, oral contraceptives
- Increased nucleation of cholesterol crystals
- Increased pronucleating factors (mucins, Ig)
- Decreased anti-nucleating factors (Apo AI/II)
- Hypersecretion of mucous
- Trap nucleated crystals
Describe the pathophysiology of biliary colic
- Person ingests fatty meal
- Fat in intestines triggers I cells in duodenum to release CCK
- CCK triggers gallbladder to contract (and sphincter of Oddi to relax)
- Gallstone lodged into cystic duct
- Increase pressure
- Trigger pain
- Subsides after 30-60 min when gallbladder relaxes
Pathogenesis of pigment stones
- Hepatocyte secretes increased amount of unconjugated bilirubin that can precipitate into Ca2+ bilirubinate
- Increased hemolysis can increase heme release, cause increased unconjugated bilirubin
- Infection can release microbial glucoronidases that hydrolyze bilirubin glucoronides. This increased unconjugated bilirubin and forms brown stones
Liver function tests
- Serum bilirubin
- Alkaline phosphatase
- ALT
- AST
- Reflect detoxification and excretory function
- Generated during breakdown of old RBCs
- Unconjugated, lipid soluble, carried by albumin to liver
- Conjugated in liver and secreted with bile
- Increased unconjugated bilirubin -> liver dysfunction
- Reflects cholelithiasis (identify bile duct obstruction)
- Liver specific enzyme (hepatocyte damage)
- Not liver specific (but can reflect hepatocyte damage)
How do you recognize domestic violence/intimate partner violence?
What is the physician’s role/
Recognition/screening
- Trauma in sexual area
- General bruising/scrapes (different stages of healing)
- Anxiety
- Avoiding eye contact
- Abuser answers the questions
Physician’s Role
- SAFE questions:
- Stressed/safe? Afraid/abused? Friends/family know? Emergency plan/contacts?
- AVDR:
- Ask routinely; Validate that battering is wrong; Document s/sx; Refer to specialist (social worker)
What are some factors that contribute to the physican workforce shortage in Hawaii?
What are some proposed solutions?
- Local amenities, economy, practice situation (workload, schedule), job satisfaction, community relationships
- Solutions
- Increase med school class sizes (difficulty funding)
- Increase # and capacity of residency programs (funding)
- Financial incentives (NHHSP, but doesn’t address retention)
- Use of disciplinary teams
- Early exposure during school
What are the some of the key features of the Affordable Care Act?
In 2010, Obama signed Patient Protection and Affordable Care Act.
- Increase coverage
- End pre-existing condition for kids
- Keeps young adults (<26 covered)
- Increase access to affordable health insurance for uninsured
- Strengthen Medicare
- Expand Medicaid
- Hold insurance companies accountable (must justify increased prices)
- Decrease costs
- Focus on preventive care (no cost)
- Small businesses (<50 not required to give coverage, <25 qualify for tax credit)
Describe the Prepaid Health Care Act
Enacted in 1974, Hawaii was the first in the US to set minimum standards of healthcare coverage for eligible employees.
- Requires ALL HI employers to provide coverage if >20 hr/wk; meet monthly wage minimum, worked for 4 consecutive weeks
- Employers must pay at least 1/2 of cost (employees can’t pay more than 1.5% of monthly wages)
- Benefits: hospital, surgery, medical, diagnostic, maternity, disability
- Penalty ($25 or $1/employee/day, whichever is greater)
What is the definition of a patient-centered medical home?
Approach to providing comprehensive health care to ensure that they receive necessary treatment with appropriate cultural/linguistic consideration. NOT an actual establishment, just a concept.
Goals: 1) Improve experience of care 2) Improve health of populations 3) Reduce costs
Key features:
1) Easy access/communication 2) Patient registry 3) Care-management 4) Patient self-management 5) Electronic health systems
