Week 1 Small Group

Summary of Patient
Encounter
10/25/17
Week 1
Amir Ali
HPI
25 yo incarcerated AA F
Chief complaint: RUQ abdominal pain
HPI:
Pain started 7 days ago and was initially intermittent, but has been
constant for the past 4 days
Pain has no association with food or position
Some relief experienced with pain medications
Last bowel movement occurred 4 days ago
Pertinent positives
Nausea
Pertinent negatives
Fever, weight loss, vomiting, diarrhea, constipation, melena,
hematochezia, SOB, chest pain
History
PMHx: Diabetes
PSHx: None
Meds: None
Allergies: NKDA
Social Hx: Single, nonsmoker; last alcoholic drink 10/16; no
drug use
Fam Hx: Mother breast cancer; Father liver cancer
Relevant PE
Vitals: WNL
HEENT: scleral icterus
Abdomen: soft, non distended, tender to palpation in
RUQ and epigastrium, + Murphy sign, no
hepatosplenomegaly
Skin: jaundice
DDX?

Uncomplicated Gallstone disease

Choledocholithiasis
Cholecystitis
Functional gallbladder disorder
Sphincter of Oddi dysfunction
Work-Up
25 y/o AA F w/ 7 day hx of RUQ abdominal pain with with
nausea. PE: + murphy sign and jaundice. - fever or
leukocytosis.
Imaging:
Transabdominal ultrasound (TUS)
MRCP
ERCP
Labs: CBC, Electrolytes (incl. Mag. Phos), Troponin, PT/aPTT/INR,
lipase, Hepatitis panel, UA, Ucx, LFTs
EKG
DIAGNOSIS
Choledocholithiasis
Subsequent Course
ERCP
Laparoscopic Cholecystectomy
Post-op currently
Clinical Question #1
Clinical Question (workup/diagnosis):
What is the workup for a patient with suspected gallbladder disease?
Answer:

Source(s): UpToDate
Clinical Question #2
Clinical question: (Treatment options/outcomes)
What are the indications for functional endoscopic sinus surgery in the
context of rhinosinusitis?
Answer:
Failed medical management for acute, recurrent-acute or chronic
rhinosinusitis
Complicated rhinosinusitis (evidence of spread outside of the nasal cavity
and paranasal sinuses to CNS, orbit or surrounding tissues)
Fungal rhinosinusitis
Obstructive nasal polyposis
Sinus mucoceles

Source(s): Otolaryngology Head and Neck Surgery Clinical Reference Guide-Pasha

Preoperative Risk Assessment-Diabetes
Patients with diabetes more likely to undergo operations, longer
hospital stays, increased rates of postoperative death and
complications
Elevated postop blood glucose levels linked to greater chances of
surgical site infections (linear correlation)
Blood glucose target levels 120-180 mg/dL (if >180 mg/dL day of
procedure, insulin infusion begun)
Control that is too tight may lead to hypoglycemia and complications
Preoperative Risk Assessment-Diabetes
Clinical Evaluation
Diabetic history
Type of diabetes
Timeline
Long-term complications
Cardiopulmonary risk factors
Hypertension
Obesity
Chronic kidney disease
Cerebrovascular disease
Autonomic neuropathy
Assessment of glycemic control (blood glucose log, average blood glucose
levels, etc.)
Diabetic therapy regimen (type, dosing, timing)
Other pharmacological therapy
Preoperative Risk Assessment-Diabetes
Laboratory Studies
Blood glucose level
Hemoglobin A1C
Creatinine
Baseline EKG
Medication Adjustments
Medication Prior to Procedure
Injectables (Exenatide, Do not take the morning of
Symlin) procedure.
Glargine Take usual dose PM before or
AM of procedure
Detemir Take usual dose PM before or
AM of procedure
NPH usual dose AM of procedure
Mixed insulins Do not take AM of procedure
Regular insulin Do not take AM of procedure
Lispro Do not take AM of procedure
SQ insulin infusion Requires individualized recs;
pumps generally continue basal rate
and correctional doses
After Procedure
Resume when eating.
Resume usual schedule after
procedure
Resume usual schedule after
procedure
Resume normal when
eating, dose when NPO
Resume when eating
Resume when eating
Resume when eating
Resume meal-time boluses
when eating again
 Oral Medication Adjustments
Medication Prior to Procedure After Procedure
Short-acting Do not take AM of procedure Resume when eating
sulfonylureas
Long-acting Do not take AM of or PM before Resume when eating
sulfonylureas procedure
Biguanides Do not take AM of; Do not take day Resume when eating. After
prior to procedure if receiving contrast dye wait 48 h and repeat
contrast dye creatinine prior to restarting
Thiazoledinediones Do not take AM of procedure Resume when eating
Alpha-glucosidase Do not take AM of procedure Resume when eating
inhibitors
DPP-4 inhibitors Do not take AM of procedure Resume when eating
Meglitinides Do not take AM of procedure Resume when eating
References
Doherty, G. M. (2010). Current diagnosis & treatment: Surgery. New
York: Lange Medical Books/McGraw-Hill.
Khan, N. A., MD, MSc, Ghali, W. A., MD, MPH, & Cagliero, E., MD.
(2015, August 26). Perioperative management of blood glucose in
adults with diabetes mellitus. Retrieved May 11, 2016, from
http://www.uptodate.com/contents/perioperative-management-of-
blood-glucose-in-adults-with-diabetes-mellitus