by Laurie Dickson

Valvular Heart Disease

 Heart contains     Two atrioventricular valves Mitral Tricuspid   Two semilunar valves Aortic Pulmonic  Valvular Disease

Valvular Heart Disease

 Types of valvular heart disease depend on  Valve or valves affected  Two types of functional alterations   Stenosis Regurgitation   HeartPoint: HeartPoint Gallery Flashcards about Ch 19 NETI KQ- on your own

Valvular Heart Disease

 Valvular disorders occur  in children and adolescents primarily from congenital conditions  in adults from degenerative heart disease  Risk Factors  Rheumatic Heart Disease MI  Congenital Heart Defects  Aging  CHF

Pathophysiology

 Stenosis- narrowed valve, increases afterload  Regurgitation or insufficiency- increases preload. The heart has to pump same blood  **Blood volume and pressures are reduced in front of the affected valve and increased behind the affected valve.

 This results in heart failure  All valvular diseases have a characteristic murmur murmurs

Mitral Valve Stenosis

Fig. 37-9 Fish mouth

Mitral Stenosis

 Dec. flow into LV  LA hypertrophy  Pulmonary pressures increase  Pulmonary hypertension  Dec. CO  Early symptom is DOE  Later get symptoms of R heart failure  A fib is common- anticoagulants  Usually secondary to rheumatic fever

Mitral Regurgitation

 Regurg of blood into LA during systole  LA dilation and hypertrophy  Pulmonary congestion  RV failure  LV dilation and hypertrophy-to accommodate inc. preload and dec CO

Mitral Regurgitation

MitraClip 3D Animation

Mitral Valve Prolapse

 A type of mitral insufficiency  Usually asymptomatic- click murmur  May get atypical chest pain related to fatigue  Tachydysrhythmias may develop  Risk for endocarditis may be increased

Mitral Valve Prolapse

Live Search Videos: mitral valve prolapse Midsytolic click & late systolic murmur A&P 1 Heart part 1

Fig. 37-10

Mitral Valve Prolapse

 Usually benign, but serious complications can occur  Mitral valve regurgitation  Infective endocarditis  Sudden death  Cerebral ischemia  heart association guidelines

Mitral Valve Prolapse

 Clinical manifestations       Most patients asymptomatic for life Murmur from insufficiency that gets more intense through systole  Late or holosystolic murmur Clicks mid to late systole that may be constant or vary beat to beat Dysrhythmias Paroxysmal supraventricular tachycardia Ventricular tachycardia    Palpitations Lightheadedness Dizziness

Mitral Valve Prolapse

 May or may not be present with chest pain  If pain occurs, episodes tend to occur in clusters, especially during stress  Pain may be accompanied by dyspnea, palpitations, and syncope  Does not respond to antianginal treatment

Aortic Stenosis

Aortic Valve Problems

Aortic Stenosis

 Increase in afterload  Reduced CO  LV hypertrophy  Incomplete emptying of LA  Pulmonary congestion  RV strain

Symptoms

 S yncope  A ngina  D yspnea

This triad reflects left ventricular failure

Aortic Stenosis

 May be asymptomatic for many years due to compensation  DOE, angina, and exertional syncope are classic symptoms  Later get signs of R heart failure  Untreated-poor prognosis- 10-20%sudden cardiac death  Poor prognosis when experiencing symptoms and valve obstruction is not relieved  Nitroglycerin is contraindicated because it reduces preload

Aortic Regurgitation

Aortic Regurgitation

 Get increased preoad- 60% of SV can be regurgitated  Characteristic

water hammer pulse

 A jerky pulse that is full and then collapses because of aortic insufficiency (when blood ejected into the aorta regurgitates back through the aortic valve into the left ventricle ).  Also called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse.

YouTube - Corrigan's sign

 Regurgitation of blood into the LV  LV dilation and hypertrophy  Dec. CO Echocardiography

Aortic Valve Regurgitation

 Clinical manifestations  Sudden manifestations of cardiovascular collapse  Left ventricle exposed to aortic pressure during diastole  Weakness  Severe dyspnea  Chest pain  Hypotension  Constitutes a medical emergency

Tricuspid and Pulmonic Valve Disorders

 Uncommon  Both conditions cause an increase in blood volume in R atrium and R ventricle  Result in Right sided heart failure

Diagnostic Tests

 Echo- assess valve motion and chamber size  CXR  EKG  Cardiac cath- get pressures

Medications

 Like Heart Failure  ACE inhibitors   Digoxin Diuretics   Vasodilators Beta blockers   Anticoagulants *Prophylactic antibiotics

Medical/ Surgical Treatment

 Percutaneous balloon valvuloplasty  Surgical therapy for valve repair or replacement:  Valve repair is typically the surgical procedure of choice   Open commissurotomy- open stenotic valves Annuloplasty- can be used for both  Valve replacement may be required for certain patients Heart valve surgery     Mechanical-need anticoagulant Biologic-only last about 15 years Ross Procedure MedlinePlus: Interactive Health Tutorials

 YouTube - Robotic Mitral Valve Repair Surgery Animation

Ross Procedure

This is an excised porcine bioprosthesis.

The main advantage of a bioprosthesis is the lack of need for continued anticoagulation

. The drawback of this type of prosthetic heart valve is the limited lifespan, on average from 5 to 10 years (but sometimes shorter) because of wear and calcification.

This is a mechanical valve prosthesis of the more modern tilting disk variety (for the mitral valve). Such mechanical prostheses will last indefinitely from a structural standpoint, but the patient requires continuing anticoagulation because of the exposed non biologic surfaces.

Medical Animation. Aortic valve replacement

Nursing Diagnoses

 Activity intolerance  Excess fluid volume  Decreased cardiac output  Ineffective therapeutic regimen management

What is new?

 Percutaneous Transcatheter Heart Valve Implantation  Metallic clip -for the treatment of mitral regurgitation  Longer-lasting replacement valves  Stem cell research and the use of endothelial cells

Cardiomyopathy

 Condition is which a ventricle has become enlarged, thickened or stiffened.  As a result heart’s ability as a pump is reduced

Cardiomyopathy

 Primary-idiopathic  Secondary   Ischemia- from CAD infectious disease   exposure to toxins Metabolic disorders   Nutritional deficiencies Pregnancy -alcohol, cocaine

3 Types

 Dilated  Hypertrophic  Restrictive

Pathophysiology Dilated

 Most common- heart failure in 25-40%  Cocaine and alcohol abuse  Chemotherapy, pregnancy  Hypertension  Genetic  * Heart chamber dilate and contraction is impaired and get dec. EF%  *Dysrhythmias are common- SVT Afib and VT  Prognosis poor-need transplant

This very large heart has a circular shape because all of the chambers are dilated. It felt very flabby, and the myocardium was poorly contractile. This is an example of a cardiomyopathy.

Normal weight 350 gms now 700 gms

Pathophysiology Hypertrophic-HOCM

 Genetic  Also known as IHSS or HCM  Get hypertrophy of the ventricular mass and impairs ventricular filling and CO  Symptoms develop during or after physical activity  Sudden cardiac death may be first symptom  Symptoms are dyspnea, angina and syncope

HOCM Patho

 1. Massive ventricular hypertrophy  2. Rapid, forceful contraction of the LV  3. Impaired relaxation or diastole  4. Obstruction to aortic outflow  Primary defect is diastolic filling  **HCM most common cause of SCD in young adulthood

There is marked left ventricular hypertrophy, with asymmetric bulging of a very large interventricular septum into the left ventricular chamber. This is hypertrophic cardiomyopathy. About half of these cases are genetic. Both children and adults can be affected, and sudden death can occur.

HOCM

 Symptoms  Dyspnea  Fatigue-dec CO  Angina, syncope  S4 and systolic murmur  Diagnostics  Echo- TEE  Heart cath Fig. 37-14 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Interventions

Goal- improve vent filling and relieve LV outflow obstruction  Beta blockers- metoprolol  Calcium channel blockers  Digoxin- only for A-fib if present  Anti-arrhythmics- amiodorone or sotalol  ICD- to dec. risk of sudden death  AV pacing

HOCM treatment

Ventriculomyotomy and myomectomy- incising the septum muscle and removing some of the hypertrophied muscle PTSMA- alcohol induced percutaneous trans luminal septal myocardial ablation inject alcohol into small branch of LAD which causes ischemia and MI of septal wall. (Grey’s Anatomy episode relief of heart failure  Live Search Videos: cardiomyopathy

Nursing

 Relieve symptoms  Prevent complications  Provide pysch and emotional support  Teaching   Avoid strenuous exercise and dehydration Avoid anything increasing the SVR (afterload) makes obstruction worse  If chest pain- rest and elevation of feet for venous return  Avoid vasodilators like nitroglycerine- decrease venous return to the heart

Pathophysiology Restrictive

 Least common  Rigid ventricular walls that impair filling  Contraction and EF normal  Signs of CHF  Prognosis-poor

Diagnostics

 Echo-wall motion and EF  EKG  CXR  Hemodynamics  Perfusion scan  Cardiac cath  Myocardial biopsy

Treatment

Medications Same as for heart failure except for hypertrophic Surgery  Vad-bridge to transplant  Heart Transplant  Myoplasty  ICD- antiarrhythmics are negative inotropes  Dual chamber pacemaker  Hypertrophic- excision of ventricular septum myotomy, inject denatured alcohol in coronary artery that feeds the top portion of septum.

Nursing Diagnoses

 Decreased Cardiac Output  Fatigue  Ineffective Breathing Pattern  Fear  Ineffective Role Performance  Anticipatory grieving

Case study 15

Ms. C. 81y/o admitted to CCU with SOB. She has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only med ordered is MSO4 2-4mg IV as needed for chest pain or dyspnea.

As you go to assess her you find her in bed at 60 degree angle. She is pale, has circumoral cyanosis and respirations are rapid and labored.

Question 1 What action should you take first?

1. Listen to breath sounds 2. Ask when the dyspnea started 3. Increase her O2 to 6L minute 4. Raise the HOB to 75-85 degrees

Case Study 15- #2

 Which one of these complications are you most concerned about, based on your assessment?

 1. Pulmonary edema  2. Cor pulmonale  3. Myocardial infarction  4. Pulmonary embolus

#3

 Which action will you take next?

 1. Call the physician about client’s condition.

 2. Place client on a non-rebreather mask with FiO2 at 95%.

 3. Assist client to cough and deep breathe.

 4. Administer ordered morphine sulfate 2mg IV.

#4

 What additional assessment data are most important to obtain at this time?

 1. Skin color and capillary refill  2. Orientation and pupil reaction to light  3. Heart sounds and PMI  4. Blood pressure and apical pulse

#5

 Client’s B/P is 98/52 and AP is 116 and irregular in ST rate 110-120 with frequent multifocal PVC’s. You call the physician and receive these orders. Which one should be done first?

 1. Obtain serum dig level  2. Give furosemide 100mg. IV  3. Check blood potassium level  4. Insert #16 french foley catheter

#6

 Which order could be assigned to an LVN?

 1. Obtain serum digoxin level  2. Give furosemide 100mg. IV  3. Check blood potassium level  4. Insert #16 french foley catheter

#7

     While you are waiting for the the potassium level, you give morphine sulfate 2mg IV to the the client. A new graduate asks why you are giving her the morphine. What is the best response?

1. It will help prevent any chest pain from occurring.

2. It will decrease her respiratory rate.

3. It will make her more comfortable if she has to be intubated.

4. It will decrease venous return to her heart.

#8

     Her K is 3.1. the physician orders KCL 20meq. IV. How will you administer it.

1. Utilize a syringe pump to infuse the KCL over 10 minutes.

2. Dilute the KCL in 100 ml of D5W and infuse over 1 hour.

3. Use a 5ml syringe and push the KCL over at least 1 minute.

4. Add the KCL to 1 liter of D5W and administer over 8 hours.

#9

 After you have infused the KCL, you give the lasix. Which of these nursing actions will be most useful in evaluating whether the lasix is having the desired effect?

 1. Obtain the client’s daily weight  2. Measure the hourly urine output  3. Monitor blood pressure  4. Assess the lung sounds

#10

 The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion?

 1. Lung sounds  2. Heart rate  3. Blood pressure  4. Peripheral edema

#11

 Which nurse should be assigned care for this client?

 1. A float RN who has worked on CCU step down for 9 years and has floated before to CCU  2. An RN from a staffing agency who has 5 years CCU experience and is orienting to your CCU today  3. A CCU RN who is already assigned to care for a newly admitted client with chest trauma  4. The new graduate RN who needs more experience in caring for client with left ventricular failure.

#12

 Which information would be important to report to the physician?

 1. Crackles and oxygen saturation  2. Atrial fibrillation and fuzzy vision  3. Apical murmur and pulse rate  4. Peripheral edema and weight

#13

 All meds are scheduled for 9 AM. Which would you hold until you discuss it with the physician?

 Furosemide 40mg po bid  Ecotrin 81mg po daily  KCL 10meq three times a day  Captopril 6.25mg po three times a day  Lanoxin .125mg po every other day

Aortic Aneurysms

Aortic Aneurysm - Page 5

Aorta

Largest artery Responsible for supplying oxygenated blood to essentially all vital organs

Aortic Aneurysms – Etiology and Pathophysiology

 May involve the aortic arch, thoracic aorta, and/or abdominal aorta  Most are found in abdominal aorta below renal arteries  ¾ of true aortic aneurysms occur in abdominal aorta  ¼ found in thoracic  Dilated aortic wall becomes lined with thrombi than can embolize  Leads to acute ischemic symptoms in distal branches  Important to assess peripheral pulses

Aortic Aneurysms

 Atherosclerotic plaques deposit beneath the intima  Plaque formation is thought to cause degenerative changes in the media  Leading to loss of elasticity, weakening, and aortic dilation

Aortic Aneurysms

 Studies suggest strong genetic predisposition  *Male gender and smoking stronger risk factors than hypertension and diabetes  Abdominal aortic aneurysms (AAA)  Occur in 4.1% to 14.2% of men  0.35% to 6.2% of women over 60  Cause of 16,000 deaths per year  In Canada, account for 0.7% of all mortalities

Thoracic Aortic Aneurysm Clinical Manifestations

 Frequently asymptomatic  May have substernal, neck or back pain  Coughing, due to pressure placed on the windpipe (trachea)  Hoarseness  Difficulty swallowing  Swelling (edema) in the neck or arms  Myocardial infarction, or stroke due to dissection or rupture involving the branches of the aorta

Ascending Aortic Aneurysm Aortic Arch Clinical Manifestations

ASH  Angina  Hoarseness  If presses on superior vena cava  Decreased venous return can cause   Distended neck veins Edema of head and arms

Abdominal Aortic Aneurysm Clinical Manifestations

 Abdominal aortic aneurysms (AAA)  Often asymptomatic  Frequently detected   On physical exam   Pulsatile mass in periumbilical area Bruit may be auscultated When patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)

Aortic Aneurysm Clinical Manifestations

 AAA  May mimic pain associated with abdominal or back disorders   Pain correlates to the size May spontaneously embolize plaque  Causing “blue toe syndrome” patchy mottling of feet/toes with presence of palpable pedal pulses  It can rupture causing shock and death in 50% of rupture cases 

Etiology and Pathophysiology

 May have aneurysm in more than one location  Growth rate unpredictable  Larger the aneurysm greater risk of rupture

Aortic Aneurysms

Classification

 2 basic classifications- True and False  True aneurysm  Wall of artery forms the aneurysm  At least one vessel layer still intact   Fusiform  Circumferential, relatively uniform in shape Saccular  Pouchlike with narrow neck connecting bulge to one side of arterial wall

Saccular

Fusiform

Most are fusiform and 98% are below the renal artery

Aortic Aneurysms

Classification

 False aneurysm  Also called pseudoaneurysm  Not an aneurysm  Disruption of all layers of arterial wall  Results in bleeding contained by surrounding structures

Aortic Aneurysms

Classification

 May result from  Trauma  Infection  After peripheral artery bypass graft surgery at site of anastomosis  Arterial leakage after cannulae removal

Types of Aneurysms

Fig. 38-3

Dissecting

 Blood invades or dissects the layers of the vessel wall

Dissecting aneurysms are unique and life threatening. A break or tear in the tunica intima and media allows blood to invade or dissect the layers of the vessel wall. The blood is usually contained by the adventitia, forming a saccular or longitudinal aneurysm.

Aortic dissection occurs when blood enters the wall of aorta, separating its layers, and creating a blood filled cavity.

Aortic Dissection

 Often misnamed “dissecting aneurysm”  Not a type of aneurysm  Occurs most commonly in thoracic aorta  Result of a tear in the intimal lining of arterial wall  Affects men more often than women  Occurs most frequently between fourth and seventh decades of life  Acute and life threatening  Mortality rate 90% if not surgically treated

Aortic Dissection Etiology and Pathophysiology

 As heart contracts, each systolic pulsation ↑ damaged area pressure on  Further ↑ dissection  May occlude major branches of aorta  Cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities  People with Marfan’s at risk

Marfan’s

Dissection of Thoracic Aorta

Manifes tations of Aortic D is s ection Aneurys m

    Abrupt, s evere, ripping or tearing pain in area of aneurys m Mild or marked hypertens ion early Weak or abs ent puls es blood pres s ure in upper extremities and S yncope C omplications : hemorrhage, is chemic kidneys (renal failure) , MI, heart failure, cardiac tamponade, s eps is , weaknes s or paralys is of lower extremities .

Aortic Dissection Collaborative Care

 Initial goal  ↓ BP and myocardial contractility to diminish pulsatile forces within aorta  Conservative therapy  If no symptoms  Can be treated conservatively for a period of time  Success of the treatment judged by relief of pain  Emergency surgery is needed if involves ascending aorta

Aortic Dissection Collaborative Care

 Drug therapy  IV Beta- adrenergic blocker  Esmolol (Brevibloc)  Other antihypertensive agents  Calcium channel blockers  Sodium Nitroprusside  Angiotensin converting enzyme

Aortic Dissection Collaborative Care

 Surgical therapy  When drug therapy is ineffective  or When complications of aortic dissection are present  Heart failure, leaking dissection, occlusion of an artery  Surgery is delayed to allow edema to decrease and permit clotting of blood Surgical therapy  Even with prompt surgical intervention 30-day mortality of acute aortic dissections remains high (10%-28%)

Aortic Aneurysm

Diagnostic Studies

 X-rays  Chest - Demonstrate mediastinal silhouette and any abnormal widening of thoracic aorta  Abdomen -May show calcification within wall of AAA  ECG -to rule out MI

Aortic Aneurysm

Diagnostic Studies

 Echocardiography  Assists in diagnosis of aortic valve insufficiency  Related to ascending aortic dilation  Ultrasonography  Useful in screening for aneurysms  Monitor aneurysm size

Aortic Aneurysm

Diagnostic Studies

  CT scan  Most accurate test to determine    Anterior to posterior length Cross-sectional diameter Presence of thrombus in aneurysm MRI  Diagnose and assess the location and severity  Angiography  Anatomic mapping of aortic system using contrast   Not reliable method of determining diameter or length Can provide accurate info about involvement of intestinal, renal or distal vessels

Angiography of Aneurysm

Fig. 38-2

Medical Treatment

 Anti-hypertensives  Beta blockers,   Vasodilators Calcium channel blockers  Nipride  Sedatives  Niacin, mevocor, statins Post-op anti-coagulants

Surgery

 Usually repaired if >5cm  Open procedure- abd incision, cross clamp aorta,aneuysm opened and plaque removed, then graft sutured in place  Pre-op assess all peripheral pulses  Post-op-check urine output and peripheral pulses hourly for 24 hours- (when to call Dr.)  Endovascular stents- placed through femoral artery

YouTube - Abdominal Aortic Aneurysm Graft Repair

Endo vasc ular Repai r of an Abdo minal Aorti c Aneu rysm (Courtesy of Guidant Corporatio n) YouTube - Cook's modular AAA graft an "engineering achievement"

Aortic Aneurysm

Collaborative Care

 Endovascular graft procedure, con’t  New approach is percutaneous femoral access  Advantages  Shorter operative time  Shorter anesthesia time   Reduction in use of general anesthesia Reduced groin complications within first 6 months

Nursing Management

Acute Intervention- Post-op ICU monitoring  Arterial line  Central venous pressure (CVP) or pulmonary artery (PA) catheter  Continuous ECG monitoring  Oxygen administration/Mechanical ventilation  Pulse oximetry/ Arterial blood gas monitoring  Urinary catheter  Nasogastric tube  Electrolyte monitoring  Antidysrhythmic/pain medications

Nursing Management

 Acute Intervention  Infection  Antibiotic administration  Assessment of body temperature  Monitoring of WBC  Adequate nutrition  Observe surgical incision for signs of infection

Nursing Management

 Acute Intervention  Gastrointestinal status  Nasogastric tube  Abdominal assessment  Passing of flatus is key sign of returning bowel function  Watch for manifestations of bowel ischemi a

Nursing Management

 Acute Intervention  Neurologic status  Level of consciousness  Pupil size and response to light  Facial symmetry  Speech  Ability to move upper extremities  Quality of hand grasps  Peripheral perfusion status  Pulse assessment  Mark pulse locations with felt-tip pen

Nursing Management

 Peripheral perfusion status  Pulse assessment  Mark pulse locations with a felt tip pen  Extremity assessment  Temperature, color, capillary refill time, sensation and movement of extremities

Nursing Management

 Acute Intervention  Renal perfusion status  Urinary output  Fluid intake  Daily weight  CVP/PA pressure  Blood urea nitrogen/Creatinine

Nursing Management

 Ambulatory and Home Care  Encourage patient to express concerns  Patient instructed to gradually increase activities  No heavy lifting  Educate on signs and symptoms of complications  Infection  Neurovascular changes

Nursing Diagnoses

 Risk for Ineffective Tissue Perfusion  Risk for Injury  Anxiety  Pain  Knowledge Deficit

Prevention

     1.Ultrasound is extremely effective at detecting AAAs.The U.S. Preventive Services Task Force (USPSTF) recommends that anyone aged 65 to 75 who has ever smoked undergo a one-time ultrasound screening for AAA 2.Prevent atherosclerosis 3.Treat and control hypertension 4.Diet- low cholesterol, low sodium and no stimulants 5.Careful follow-up if less than 5cm. It can grow .5cm /year

Complications

 Rupture- signs of ecchymosis  Back pain  Hypotension  Pulsating mass  Thrombi  Renal Failure

Rupture Triad

Hypotension Back pain Pulsating hematoma

Aortic Aneurysm

Complications

 Rupture- serious complication related to untreated aneurysm  Posterior rupture    Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death Severe pain May/may not have back/flank ecchymosis

Turner’s sign and Cullen’s sign

Aortic Aneurysm

 Rupture  Serious complication related to untreated aneurysm  Anterior rupture  Massive hemorrhage  Most do not survive long enough to get to the hospital  Live Search Videos: aortic aneurysm  http://www.austincc.edu/adnlev4/rnsg2331online/mo dule05/aneurysm_case_study.htm

Priority Question # 29  During the initial post-operative assessment of a patient who has just transferred to the post-anesthesia care unit after repair of an abdominal aortic aneruysm all of these data are obtained. Which has the most immediate implications for the client’s care?

 A. The arterial line indicates a blood pressure of 190/112.

 B. The monitor shows sinus rhythm with frequent PAC’s.

 C. The client does not respond to verbal stimulation.

 D. The client’s urine output is 100ml of amber urine.

Priority Question #30      It is the manager of a cardiac surgery unit’s job to develop a standardized care plan for the post-operative care of client having cardiac surgery. Which of these nursing activities included in the care plan will need to be done by an RN?

A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs.

B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake.

C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes.

D. Administer oral analgesisc medications as needed prior to assisting patient out of bed on first post-operative day.

Priority Question # 25      These clients present to the ER complaining of acute abdominal pain. Prioritize them in order of severity.

A. A 35 year old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating.

B. An 11 year old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days.

C. A 40 year old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week.

D. A 56 year old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour.