[Pa23] Clinical Medicine Updates

[Hastings, Jennifer K]

Good Evening,

I just wanted to follow up on a few items.  First, I received a question requesting clarification on Gilbert's Syndrome as to whether it is considered an intrahepatic process or a prehepatic process.  Gilbert's syndrome is considered an intrahepatic process as it refers to a deficiency in the enzyme used in glucuronidation.  This process occurs in the hepatocyte and therefore is considered intrahepatic.  Examples of prehepatic processes that can lead to jaundice would be a resolving hematoma vs. hemolytic anemia (before unconjugated bilirubin is taken up by the hepatocyte).

Second, we talked a great deal about diseases that present with a hepatocellular pattern of injury versus diseases that present with a cholestatic pattern of injury.  Diseases typically start and present with these patterns which helps on our initial evaluation to form a differential diagnosis.  However as diseases progress, and if a patient develops cirrhosis, patients can have a clinical picture of both hepatocellular and cholestatic injury.  Also, in the instance of severe acute injury/hepatitis with significant inflammation(acute viral hepatitis, toxin injury, shock liver, alcoholic hepatitis) there is typically a very high AST/ALT with a component of cholestasis as well (these patients often present jaundiced).

Third, I would like to clarify on the topic of cardiology clearance.  If you recall the patient we discussed during GI Inbox was a 65-year-old male with many cardiac risk factors with significant dyspnea.  Given that this patient was symptomatic, this patient warrants cardiology evaluation prior to sedation.  Screening in asymptomatic individuals is a much more complex topic.  Need for pre-operative cardiac screening would typically take factors such as overall CVD risk, functional status, low-risk vs. high-risk procedures into consideration.  For those of you that would like an additional resource, I have included the executive summary of the ACC/AHA guidelines for pre-operative cardiac management and treatment.  However, if interested I would recommend reading this over block break!

Lastly, I would like to highlight a few items.  Screening recommendations are for asymptomatic patients.  If a patient presents with symptoms, the focus shifts from screening evaluation to a diagnostic evaluation (screening guidelines are not used for determining the timing of an evaluation in a patient who is presenting with symptoms).   Also, as I mentioned demographics and risk factors are always helpful to factor in when evaluating patients or taking an exam.

I wish you all good luck on your exam!  Thank you so much for your attention during the GI unit.

Sincerely,
JH

Jennifer Hastings, MSHS, PA-C
Adjunct Professor
Campbell University Physician Assistant Program
jhastings at campbell.edu

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://list.campbell.edu/pipermail/pa23/attachments/20220204/6504801d/attachment-0001.htm>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: ACC_AHA Guideline Perioperative Cardiac Eval and Management.pdf
Type: application/pdf
Size: 1653033 bytes
Desc: ACC_AHA Guideline Perioperative Cardiac Eval and Management.pdf
URL: <http://list.campbell.edu/pipermail/pa23/attachments/20220204/6504801d/attachment-0001.pdf>