Atrial Fibrillation

Atrial fibrillation is a commonly encountered dysrhythmia in the hospital setting. Multiple re-entrant impulses from within the atrial myocardium overwhelm the AV node, which becomes relatively refractive to conduction and does not allow all the impulses from the atria to stimulate the ventricular myocardium. Atrial fibrillation is more common in the elderly patient. Men are at a significantly higher risk.

Signs and symptoms include: palpitations, fatigue, poor exercise tolerance, dyspnea, chest pain, syncope, and generalized weakness. Patient will also have an irregular pulse, hypotension, poor perfusion, and signs of embolization.


Hypertension is one of the greatest threats to people in North America. Hypertension is widely recognized as systolic blood pressure equal to or more than 140 mmHg, diastolic blood pressure equal or more than 90 mmHg. Hypertension is a result of a malfunction of arterial pressure control mechanisms that are centered in the central nervous system, renin-angiotensin-aldosterone system, and extracellular fluid volume.

Signs and symptoms include: recurrent headache, blurred vision, convulsions, tremors, and walking difficulties


A number of factors can initiate acute pancreatitis. Some factors include obstruction or distension of the pancreatic duct, hypertriglyceridemia, hypercalcemia, and exposure to ethanol and other toxins. As a result, pancreatic destructive enzymes (amylase and lipase) are released into the pancreas and surrounding tissues.

Signs and symptoms include: epigastric pain that radiates to flanks and back, nausea, vomiting, fever, elevated pulse, and a purple hue on the skin above the pancreas.

Abnormal Bloodwork:

  • Electrolytes (K+, Na+) if vomiting
  • WBCs increased
  • Liver enzymes increased
  • Glucose increased (transient hyperglycemia)
  • Serum Amylase and Lipase are used to make diagnosis, in 90% of cases these enzymes usually rise 3x their upper normal limit within 24 hours. Serum Lipase remains elevated for 7-14days (Enzyme indicator pancreatitis)
  • Bilirubin increased
  • Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis
  • With pancreatitis, it is believed that the pancreatic duct becomes obstructed, accompanied by hypersecretion of the exocrine enzymes of the pancreas. These enzymes enter the bile duct, where they are activated and, together with bile, back up (reflux) into the pancreatic duct, causing pancreatitis

Causes of Pancreatitis

  • #1 alcoholism
  • Gallstones (lodged in ampulla of Vater)
  • Viral infection (hepatitis)
  • Bilary tract disease
  • Medications

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Jaundice is not a disease in itself, but a sign of an underlying disease process. Jaundice is associated with the presence of bilirubin in the blood.  It often occurs when too much bilirubin is produced creating a difficulty in removing it from the blood.  Sometimes fault lies with the liver, in that some inherent defect in the liver prevents it from removing bilirubin from the body system. The last cause could be a blockage in the bile duct that decreases bile/bilirubin flow from the liver into the intestines.

Signs and symptoms of jaundice include: gray coloured stools, yellow skin, yellow eyes, dark or reddish urine,  loss of appetite, bitter taste in mouth, furry tongue, foul-smelling feces, nausea, pruritus, lethargy, slow pulse, and confusion.

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Refeeding Syndrome

  • Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Renourishment is the process of avoiding refeeding syndrome.
  • Refeeding syndrome usually occurs within four days of starting to feed. Patients can develop fluid and electrolytes disturbances, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. Most effects result from a sudden shift from fat to carbohydrate metabolism and a sudden increase in insulin levels after refeeding which leads to increased cellular uptake of phosphate. Refeeding increases the basal metabolic rate. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes including phosphate, potassium, magnesium, glucose, and thiamine. Significant risks arising from refeeding syndrome include: confusion, coma, convulsions, and death.
  • The shifting of electrolytes and fluid balance increases cardiac workload and heart rate. This can lead to acute heart failure. Oxygen consumption is also increased which strains the respiratory system and can make weaning from ventilation more difficult.
  • TX: Refeeding syndrome can be fatal if not recognized and treated properly. If potassium, phosphate, or magnesium are low they will need to be corrected. Prescribing thiamine, a multivitamin, and a mineral is recommended. Biochemistry should be monitored regularly until it is stable.

Total Parenteral Nutrition (TPN)

  • TPN is the practice of feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins.
  • TPN is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired.
  • Short-term TPN may be used if a person's digestive system has shut down (for instance by Peritonitis), and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. Long-term TPN is occasionally used to treat people suffering the extended consequences of an accident, surgery, or digestive disorder.
  • The preferred method of delivering TPN is with a medical infusion pump. A sterile bag of nutrient solution, between 500 mL and 4 L is provided. The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open. Feeding schedules vary, but one common regimen ramps up the nutrition over one hour, levels off the rate for a few hours, and then ramps it down over a final hour, in order to simulate a normal metabolic response resembling meal time. This should be done over 12 to 14 hours rather than intermittently during the day.
  • The most common complication of TPN use is bacterial infection, usually due to the increased infection risk from having an indwelling central venous catheter. In patients with frequent bacterial infections, fungal infections can also occur. Liver failure often related to fatty liver, may sometimes occur. This condition is generally due to excess in glucose provided in TPN solutions.
  • Two related complications of TPN are venous thrombosis and rarely priapism. Fat infusion during TPN is assumed to contribute to both.
  • Total parenteral nutrition increases the risk of acute cholecystitis due to complete disuse of the gastrointestinal tract, which may result in bile stasis in the gallbladder. The risk of acute cholecystitis is increased accordingly.
  • The nutrient solution consists of water and electrolytes; glucose, amino acids, and lipids; essential vitamins, minerals and trace elements are added or given separately. Previously lipid emulsions were given separately but it is becoming more common for a "three-in-one" solution of glucose, proteins, and lipids to be administered.
  • Metabolic complications include Refeeding Syndrome characterized by hypokalemia, hypophosphatemia and hypomagnesia. Hyperglycemia is common at the start of therapy, but can be treated with insulin added to the TPN solution. Hypoglycemia is likely to occur with abrupt cessation of TPN. Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration. Severe hepatic dysfunction is a rare complication. Overall, patients receiving TPN have a higher rate of infectious complications and can be related to hyperglycemia.

Laparoscopic Cholecystectomy:

The use of a laparoscope to remove the gallbladder. It is minimally invasive as it is performed through several small incisions rather than one large incision. After the initial incisions, the abdominal cavity is inflated with carbon dioxide. A camera is used to send a magnified image from inside the body to a video monitor to give the surgeon a close up view of the gallbladder and surrounding organs. With an uncomplicated procedure most people can expect to be discharged from the hospital the day after. Complications of this procedure include but are not limited to bleeding, infection, and injury to the common bile duct. Major blood vessels may be damaged or transacted when the instruments are inserted into the abdominal cavity. The procedure normally takes around 30-60 minutes.

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Type I Diabetes

Type 1 diabetes is a disease in which the pancreas does not produce insulin. Glucose builds up in the blood instead of being used for energy. The cause of type 1 diabetes remains unknown. However, it is not preventable, and it is not caused by eating too much sugar. The body’s defense system may attack insulin-making cells by mistake, but we don’t know why. People are usually diagnosed with type 1 diabetes before the age of 30, most often during childhood or their teens.

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