CS Master Deck Final

Appendicitis HYC

Pathology: Fecalith (adult / lymphoid hyperplasia (children)

Pain:

• Peri-umbilical pain —→ Mcburneys point (2/3 from BB to ASIS)

• Rovsing sign —> rebounding sign with palpation of the LLQ —> pain in the RLQ

Sxs: Nausea, vomiting, no appitite, + G/R/R

Tx: Clinical —-» CT abdomen/US (from children or pregnant women), Boards—→ always surgery

Chapman point (HY): Tip of the 12th rib, right side

DDx:

• Think about bladder pain ie UTI or kidney stone(more central pain)

• ovary/tubes/uteruses ie torsion, cysts, PID (pelvis inflammatory disorder via gonorrhea/chlamydia travel through pelvis to pariteum) ectopic pregnancy

• other ie hernia, diverticulitis (usually on left, elderly)

• Pseudoappendicitis - Yersinia enterocolitica (think viral gastroenteritis infection can cause RLQ pain)

Uses this to ask target questions: LMP, back pain, ovulation (mittelschmerz pain —→middle hurts, peritoneal irritation (follicular, swelling, fallopian tube contraction), urination issues, sexual history (ie STD)

Peptic Ulcer Disease HYC

• Dyspepsia

• DDx

• Alarm Sxs

• Pertinent positives and negatives

• Locations of ulcer

• Pathology

• Types of ulcers

• Sxs

• Dx

• Tx:

• Complications

Dyspepsia

• Burning pain in epigastric area (25 percent population have this at any given time)

DDx: Peptic ulcer disease, GERD, cancer, gastritis, pancreatitis, functional dyspepsia (no specific Sxs)

Alarm Sxs: Age > 50, melena (dark stool), anorexia —→ straight to EGD —> biopsy (via endoscopy)

Pertinent positives and negatives:

• GERD - sour taste/burps, worst after big meal or after laying down, burning/gnawing, smoking and drinking Hx, NSAID/steroid use

Locations of ulcer: Stomach or duodenum

• Gastric - worse with food

• Duodenum - initially better with food but worse in 1-3 hours.

Pathology: H Pylori (also causes gastritis), NSAID

Types of ulcers:

• Curling ulcers - burns

• Cushing ulcers - increased ICP/vents (think chronic sick patients get ulcers)

Sxs:

• Gnawing pain, 50 percent asymptomatic

Dx: EGD, Bx —→ breath test (most common)

Tx:

• No spicy foods/nsaids/smoking/drinking, proton pump inhibitors or H2 blocker or tums

• Triple therapy 2 antibiotics + proton pump inhibitor

Complications:

• Makes hole—> food and into intraperitoneal cavity —→ rigid acute abdomen;

• bleed and hemorrhage —> anemia

• ***Can develop maltoma ie H Pylori is carcinogenic

Hypothyroid HYC

• Thyroid cascade

• T4 functions

• Sxs

• DDx

• Test

• Tx

• Complications

Thyroid cascade: TRH (hypothalamus) —> TSH (ant pit) —> T4 (thyroid)

• T4 inh TRH and TSH if (T4) is high, visa vera if low

• TSH is used as our screening test, also used during treatment for adjustments (tells us how the body is doing)

• If TSH is low then T4 is high, so low TSH is associated with hyperthyroidism, so high TSH is associated with hypothyroidism

T4 functions: Movement, metabolism, mentation

Sxs: Weight gain, constipation, bradycardia, decreased DTRs (hyporeflexia), cold, fatigue, depression

DDx: Hashimoto's thyroiditis (antibodies attacking thyroid, autoimmune)

Test: TPO antibody (for Hashimoto's)

Tx: Synthroid or levothyroxine (monitor TSH levels to know how much)

Complications: Myxedema coma

• Coma

• Hypothermia —→ hypotensive

• Tx: Warm IV fluids, blankets, IV T 3/4

Hyperthyroid HYC

• Sxs

• Labs

• Tests

• DDx

• Tx

• Thyroid Storm

Sxs: Diarrhea, tachycardia —> afib, weight loss, heat intolerance, increased DTRs, anxiety

Labs: TSH will be low, T4 will be high

Tests: RAIU scan —> light up areas are actively making T4

DDx:

• Graves disease (autoimmune, antibodies(TSI) attack and tell the thyroid to grow big); whole areas will glow with RAIU —> whole thyroid making T4

• Toxic adenoma (one nodule growing) or MNG (multi nodular goiter) —> RAIU shows one or 4 light up (Tx surgery or radioablation)

• thyroiditis (inflamed so spilling T4, can go back to normal or burn out which leads to hypothyroidism) —> associated with postpartum/viral, RAIU is negative (cold scan, not actively up taking iodine, T4 is high so TSH turns off thyroid)

Sxs: Exophthalmos, pre-tibial myxedema

Tx: thioamides (decreased T4, used in thyroid storm)

Thyroid Storm: severe tachycardia and/or afib (leads to hemodynamic unstably), shock, febrile (>104),

• Tx cold fluids, beta blocks, thioamides

Ectopic Pregnancy HYC

• Definition

• Risk factors

• Clinical presentation

• DDx:

• Diagnosis

• Management

• Follow up

Definition: Blastocyst implantation outside of the endometrium

• MCC early maternal death (10 fold decrease in last 35 yers d/t imaging)

• ~2% of pregnancies, 95% in fallopian tube

Risk factors

• Previous ectopic pregnancy (top risk factor), previous tubal surgery, Hx of infertility, endometriosis, PID (Hx of STD ie chalmydia), smoking (decrease motility), age

Clinical presentation

• Early preg. Sxs less common due to lower hormone levels

• Suspect in reproductive age w vaginal bleeding and/or pain

  • No confirmed intrauterine preg, amenorrhea > 4 weeks

  • Hx of conception with IVF

  • Hemodynamically unstable w acute abdomen, no obvious source

DDx:

• Normal pregnancy (implantation bleeding)

• Abortion (threatened, inevitable, complete)

• Cervical, vaginal, uterine (laceration, infection ,polyps, subchorionic hematoma)

• Gestational trophoblastic disease (associated with high bHCG)

• Other ie UTI, nephrolithiasis, appendicitis, ovarian pathology/mass, round ligament pain

Diagnosis

• Transvaginal ultrasound more sensitive than transabdominal

  • No intrauterine preg and ring of fire

  • Extrauterine gestational sac, adnexal mass

  • intraperitoneal bleeding (free fluid, coagulates)

  • Gold standard —→ Dx with laparoscopy

• Rare —> heterotopic pregnancy (both intrauterine and one ectopic)

• US and HcG levels used for diagnosis

  • Transvaginal 1500-2000 HcG should be seen with IUP

  • Transabdominal above 5000 HcG should be seen on IUP

  • bHcG should double q48hours (if pt is stable and preg is unknown location) —> then can repeat ultrasound (ie 1500 on Monday should be 3000 on Wednesday)

Management

• Methotrexate

  • Inhibits folate synthesis (stop prenatal vitamins), multiple dosaging regimens, Follow LFTs, bHCG until zero, reverse w leucovorin

  • Indications: Asymptomatic compliant pt (needs to follow up for HCG labs), bHCG < 5000, unruptured sac, no fetal cardiac activity, size < 4cm

• Surgical

  • Indications: non compliant ( no f/u), hemodynamically unstable, desires surgery

  • Laparoscopy vs laparotomy

    • Depends on hemodynamic factors, possible to preserve fertility w salpingostomy

Follow up

• More likely to have another one now, resolution of preg needs to be confirmed w neg preg test (before becoming preg again), counsel on future preg and offer BC if no desire to become preg in future

Seizure HYC

Medical Jurisprudence

• Definition of death

• Upper brain death

• Organ donation

Definition of death

• Historical criteria: when an individual’s cardiac and pulmonary function cease

• Modern criteria, as defined in the Uniform Determination of Death Act (1981):

  • “An individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain

• Including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards.”

  • Whole Brain Death: functioning of the entire brain ceases, including the brain stem

Upper brain death

• Persistent Vegetative State (PVS): When an individual has irreversibly lost all cognitive function. Not considered to meet the standard criterions of death in any states

• Organ Procurement for Transplantation: Allowing neurological criteria to determine death increases the availability of viable donor organs

Organ donation

• Uniform Anatomical Gift Act

  • Regulates posthumous organ donation

  • Competent adults may gift their organs in advance of death (or by a proxy decision-maker at time of death death) for education and research, as well as for transplantation

• National Organ Transplant Act

  • Established the Organ Procurement and Transplantation Network (OPTN) in the attempt to better allocate organ donations to recipients. Banned the sale of organs (exceptions apply, i.e., blood, sperm, oocytes)

• Organ Procurement

  • Post-Mortem: authorization must be given to gift organs

  • Living Persons: may donate renewable tissues or those in abundant supply, or gift non-essential organ

• Organ Allocation

  • OPTN: oversees organ procurement and allocation for organ transplantation in U.S.

  • United Network of Organ Sharing (UNOS): nonprofit organization tasked with managing OPTN

• Transplant centers

  • Each individual transplant center applies its own criteria in determining waitlist eligibility

  • Factors considered for eligibility can include expected quality of life after transplant, likelihood of successful surgery, length of time the transplant is expected to benefit the recipient (+geographic zone)

Medical Jurisprudence

• Capacity v. Competence

• Decision making authority: Living Wills vs Durable Power of Attorney for Healthcare

Capacity

• a person’s ability to freely make and communicate their health care decisions.

• Patient must: understand information provided about their health care decision, clearly communicate their choice, appreciate and evaluate the facts relating to the decision, display reasoned decision-making

Competence

• a legal determination of whether an individual is able to freely make conscious decisions

Decision making authority

• Hierarchy: competent patient, advanced healthcare directive, next of kin, ethics committee

• Advanced healthcare directive

  • Living Wills: a legal document describing how an individual wishes medical decisions to be made when they are no longer able to make such decisions for themself

  • Durable Power of Attorney for Healthcare: a legal document appointing a proxy decision-maker for healthcare decisions for an individual in the event they cannot make their own healthcare decisions

• Next of kin

  • State statutes establish the hierarchy of decision-making authority for next of kin ie Spouse, adult children, parents, adult siblings. Can also include other relatives or close friends dependent on state (if a better option is not available for the patient)

• Ethics committee

  • If a patient does not leave an advance healthcare directive and a surrogate decision-maker cannot be established, then an ethics committee will likely make the healthcare decisions for the patient

Medical Jurisprudence

• Discussion making for minors

• End of life decision making

• Withdraw treatment

• Physician aided suicide

• Medical Futility

Discussion making for minors

• U.S. Supreme Court acknowledged a right for parents to make their own decisions regarding how they raise their children, but the right is subject to reasonable limits

• The state may intervene in a parent’s decisions when the health and safety of the child is at risk

End of life decision making

• Patient’s Individual Interests ie Personal autonomy/Right to informed consent, Right to privacy

• State’s Interests: Ie Preservation of life, Integrity of the medical profession, Suicide prevention, Protection of innocent third-party welfare

• Refusals: For competent adults, courts favor preserving a patient’s autonomy over the state’s interests. Courts are disinclined to give the government the authority to choose whose lives should be preserved

Withdraw treatment

• See picture

• Withholding vs withdraw

  • Once deemed more acceptable than withdrawing treatment. Courts also no longer use the extent of a treatment’s invasiveness as a factor in whether the patient may refuse; even minor invasiveness is still deemed to be some form of bodily invasion that a patient may refuse

Physician aided suicide

• Competent patient has a right to refuse medical treatment even if doing so may result in death; however, the Supreme Court has decided that there is no right to assistance in dying. 11 states (plus District of Columbia) allow for physician aid in dying, through statute (less than 6 months to live, has to show interest for > 15 days)

Medical Futility

• A physician’s determination that a treatment will not provide a benefit to the patient

• Two measures used to determine treatment futility:

  • Qualitative Measure: evaluate whether the treatment would result in sufficient benefit to justify use

  • Quantitative Measure: evaluate the likelihood the treatment will have the desired effect

Reproductive law

• Traditional vs gestational surrogacy arrangements

• Contraceptions

• Abortions

The United States Supreme Court recognizes:

• Right to Privacy (in the bedroom) + Right to Procreate + right to pursue assisted reproduction (Artificial Insemination by Donor, IVF (divorce = potential to become child or custody agreement as seen in court), Surrogacy Arrangements( remember implication with sperm donors, ie will not have parental access unless that is that intent, baby to married woman = husband is the father)

Traditional vs gestational surrogacy arrangements

• Traditional: Father sperm + surrogate egg —→ baby (surrogate has to give up right but it is not enforceable / illegal)

• Gestational surrogacy —→ surrogate does not provide egg (iffy areas ie birthing mom vs owner of egg)

Contraceptions

• The United States Supreme Court recognizes a constitutional right to privacy coupled with a right to choose not to procreate ie right to use of birth control

• Defining Cases; Griswold v. Connecticut (1965) (sexual acts vs procreation) and Eisenstadt v. Baird (1972) (right to privacy extends beyond the bed, free from unwanted governmental intrusion to bear a child)

Abortions

• The United States Supreme Court does not recognize a constitutional right to abortion

• Defining Cases:

  • Roe v. Wade (1973) (liberty right to pregnancy, if restrictions are put on adoption to interested of state and to serve state interest)

    • Trimester framework: 1st state couldn’t impose, 2nd state could if imposed to maternal health, 3rd state could regulate abortions due to risk of life of mother or baby

  • Planned Parenthood of Southeastern Pennsylvania v. Casey (1992) (government could put limitations of abortion as long as it didn’t increase burden to get a abortion)

  • Dobbs v. Jackson Women’s Health Organization (2022) (up to state to keep regulations)

  • - Look into nevada leg ************

Occupational Safety and Health Act (OSHA)

• Purpose/What does it do?

• Clause

• Reports

Purpose:

• ensure safe and healthy working environments

What does it do?

• Sets industry health and safety standards

• Enforces established standards

• Provides education, training, outreach, and compliance assistance

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Clause

• Employer must ensure that the workplace is “free from recognized hazards that are causing or are likely to cause death or serious physical harm” to employees

• Employer must undertake a hazard assessment of the workplace and put into place procedures to mitigate the risk of an occupational incident

• Healthcare Facility Standards:

  • Bloodborne Pathogens

  • Hazard Communication

  • Personal Protective Equipment

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Reports

• Most violations are precipitated by an employee complaint filed with OSHA

• Whistleblower safeguards protect employees from employer retaliation

Health Insurance Portability and Accountability Act (HIPAA)

Main Purpose:

• To protect patient and health insurance member’s information privacy and prevent disclosure of their protected health information without their consent or knowledge

What does it do?

• Privacy Rule: covered entities cannot disclose a patient’s Protected Health Information (PHI) without the patient’s prior written authorization

  • Covered entities may disclose PHI under two situations (1) to comply with a court order, warrant, subpoena, or administrative request, OR (2) for treatment, payment or other healthcare operations (TPO)

• Security Rule: covered entities must implement administrative, physical, and technical measures to protect electronic PHI

Emergency Medical Treatment and Active Labor Act (EMTALA)

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False Claims Act

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Anti-Kickback Statute

Emergency Medical Treatment and Active Labor Act (EMTALA)

• Purpose:

  • To regulate the duty to treat in emergency or life-endangering situations

• What does it do?

  • Places a ‘duty to treat’ on hospitals (and physicians)

• Procedural steps that must be followed:

  • An individual who arrives at a hospital’s emergency facility must be screened, if the hospital staff determines that an emergency medical condition exists, the individual must be rendered life-saving care until they are stabilized

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False Claims Act

• Main Purpose:

  • To protect the government from being defrauded

• What does it do?

  • Imposes civil and criminal liability upon individuals or entities who knowingly deceive or make misrepresentations to the government

  • Applied to health care, the FCA creates liability for knowingly submitting false or fraudulent claims to government-funded medical programs

• Violators may be fined up to three (3) times the government’s loss, plus a penalty between $5,500 - $11,000 per false claim filed

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Anti-Kickback Statute

• Main Purpose:

  • To protect patients from having their treatment decisions be influenced by a providers’ potential financial gain and self-interest

• What does it do?

  • Illegal to offer “remuneration” to generate or reward patient referrals or increased business involving any good or service paid by government-funded programs

  • Remuneration is anything of value and can include meals, hotel stays, cash, excessive compensation, etc.

• Liability on both sides, Intent is a key element to liability under the statute; illegal to pay remuneration when the payments are intended to reward or induce an increase in health care business

• Results in Fines, Jail sentences, and Exclusion from participation in the Federal health care programs

Physician Self-Referral Law (Stark Law)

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Exclusion Statute

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Civil Monetary Penalties Law

Physician Self-Referral Law (Stark Law)

Purpose?

• To prevent health care fraud and a provider’s referral decisions being motivated by self-interest and self-gain

What does it do?

• Physicians cannot make referrals to to entities with which the physician or physician’s immediate family member has a financial relationship

• Applies to referrals for designated health services paid by Medicare

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Exclusion Statute

• If an individual or entity has been convicted of certain criminal offenses, they are required to be excluded from participating in all federal health care programs

• Convictions leading to exclusion:

  • Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid

  • patient abuse or neglect

  • felony convictions for other health-care-related fraud, theft, or other financial misconduct

  • felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances

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Civil Monetary Penalties Law

• The Office of Inspector General may seek civil monetary penalties, assessments, or Federal program exclusion from individuals or entities for engaging in prohibited conduct

• Prohibited conduct that invokes Civil Monetary Penalties Law includes violations of EMTALA, False Claims Act, Anti-Kickback Statute, and Physician Self-Referral Law

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***Tips

• Establish and/or comply with compliance programs to ensure you do not submit false or fraudulent claims or violate referral laws

• Use your critical thinking skills to evaluate offers and agreements made with individuals and entities within the health care industry

• Practice proper patient evaluation and charting to lower risk of making mistakes