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NR511 Midterm Study Guide Worksheet
Recommended tips for success:
- Studying View/review the material a minimum of three times: a. Read assigned chapters, view module content and take notes by filling in the grid below. b. Create 5x8 flash cards for each disease using your notes and the grid. Test yourself or ask your friends and co-workers to test your knowledge using the flashcards. Success is a team sport. c. Review the flash cards and grid within 24hrs of the exam.
- Testing a. Do not change your answer unless you are very sure that it is wrong. b. Before answering, carefully read the root of the question. c. Eliminate at least two of the answers and then use your critical thinking to narrow the choices. There may be two correct answers. Your job is to distinguish which of the answers is the MOST correct. d. Make sure that you are rested, nourished and in a good environment for test taking. Directions : For each condition, fill in:
- risks associated with the condition (e.g. alcoholism and pancreatitis)
- significant subjective and objective findings especially those unique to the condition (e.g. appendicitis and RLQ abdominal pain)
- the best diagnostic test used to confirm or diagnose
- first line treatment with a second line option for the condition
- most important patient education regarding the treatment (answers should follow EBM guidelines) Disease Risk Subjective Finding Objective Findings Diagnostics Treatment Education GI DISORDERS Appendicitis -Most common between 10- 30yrs; but can occur at any age; rare in infants -Dx made clinically, based primarily on H&P exam -May have HTN tachy proportional to pain\symptoms -Labs are not diagnostic and nonspecific -Surgical; preoperative care, NPO, correction of fluid\electrolyte imbalances -F\U with surgeon -Ambulation after
and older adults -men more at risk
- Diets low in fiber, high in fat, refined sugars, & other carbs at increased risk.
- Obstruction of appendix is cause of majority of appendicitis
- contributing factors: Intra- abd tumors, positive family hx
- Recent roundworm infection or viral GI infection
- Classic presentation includes acute onset of mild to severe colicky, epigastric, or periumbilical pain
- Pain is vague at first then localizes within 24hrs to RLQ
- Pain exacerbated by walking\coughing
- Men may feel radiated pain in testes
- Abd muscle rigidity, N\V, anorexia
- Mildly elevated temp 99-100F common
- If RLQ accompanied by shaking chills, perforation should be suspected
- Older adults may present with weakness, anorexia, abd distention, mild pain leading to delayed dx and increased morbidity. -When lying flat, may flex R knee to relieve tension in abd muscle -Pain with palpation in abd, diffuse in early stages. Localized to RLQ later -Positive for rebound pain; ask pt to cough to localize pain location -Sudden cessation of pain means perforation and is ER -Women should have urine human chorionic gonadotrophi n to r\o ectopic pregnancy - +Rovsing’s Sign- deep palpation & release in LLQ causes rebound pain in RLQ - +Psoas Sign - lift R leg against gentle pressure causes pain - +Obturator Sign- flex R hip & knee and slowly rotate internally causes pain - +McBurney’ s Sign - pain with pressure applied to point between umbilicus & ilium - x-ray\CT helpful when paired with positive H&P -Avoid narcotics -Atb with 3rd gen cephalosporin; Ex: ampicillin, gentamycin, flagyl surgery -Adv diet when bowel sounds return -Return to hosp with s\s of infection -Avoid heavy lifting for at least 2 wks
or dermatitis herpetiformis Type 1 diabetes Down syndrome or Turner syndrome Autoimmune thyroid disease Microscopic colitis (lymphocytic or collagenous colitis) Addison's disease fatigue, bone or joint pain, arthritis, osteoporosis, or osteopenia (bone loss) liver and biliary tract disorders (transaminitis, fatty liver, primary sclerosing cholangitis, depression or anxiety peripheral neuropathy seizures or migraines missed menstrual periods infertility or recurrent miscarriage canker sores inside the mouth dermatitis herpetiformis (itchy skin rash) B12 deficiencies) osteoporosis or osteopenia (bone loss) hypothyroidism Pts with dermatitis herpetiformis found to have signs of celiac disease on intestinal biopsy. pts have IgA deficiency and will falsely test negative) duoden al biopsie s Test for nutritional deficiencies associated with malabsorption of C.D. (hemoglobin, iron, folate, vit B12, Calcium, and Vitamin D.) help. Some pts may need treatment with immunomodulating agents. deficiencies that do not cause them to feel ill, such as anemia due to iron deficiency or bone loss due to vitamin D deficiency. However, these deficiencies can cause problems over the long term. Untreated celiac/developin g certain types of gastrointestinal cancer. This risk can be reduced by eating a gluten- free diet. Cholelithiasis is the formation of gallstones and is found in 90% of patients with cholecystitis. --Risk factors-- types of stones Patient complaint of indigestion, nausea, vomiting (after consuming meal high in fat), and pain in RUG or epigastrium that may radiate Right side involuntary guarding of abdominal muscles, Positive Murphy's sign, possible palpable gallbladder, Low Mild elevation of WBC up to 15, 000 Abdominal Xray: Quick, noninvasive,
a. Initial
management-- begins
with definitive
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Carcinoma less common in patients with CD due to treatment sometimes cramping in the rectum. Moderate-4- loose bowel movements per day perianal inflammation, rectal tenderness, and blood in stool. S/Sx of peritonitis and ileus diarrhea. CBC to check for anemia, eval for hypocalcemia , vit D deficiency., Initially oral prednisone 40- mg/d, tapered over 2- 4 months, then can have daily maintenance dose of 5- to decrease bowel motility and promote healing. Low residue diet when obstructive sx
colectomy containing more blood and mucus and other sx such as tachycardia, weight loss, fever, mild edema. Severe- frequent bloody bowel movements (6- 10), abd pain and tenderness, sx of anemia, hypovolemia, impaired nutrition. Most common sx are abd cramping/tendern ess, fever, anorexia, wt loss, spasm, flatulence, RLQ pain or mass may be found depending on severity of crohns. Tender mass in RLQ, anal fissure, perianal fissure, edematous pale skin tags. Extra intestinal finding may be episcleritis, erythema nodosum, nondeforming peripheral arthritis, and axial arthropathy hypoalbumine mi a, and steatorrhea. LFT to screen for primary sclerosis cholangitis, and other liver problems assoc with IBD. Check fluid and electrolytes. May have elevated WBC count and sed rate and prolonged prothrombin time. Barium upper GI series, colonoscopy, and CT to determine bowel wall thickening or abscess formation 10mg/d. Sulfasalazine for mild to moderate CD 500 mg BID, increased to 3-4 g/d. Clinical improvement in 3- wks, and then tapered to 2-3 g/d for 3-6 months, this medication interferes with folid acid absorption and patient must take supplements. Metronidazole effective in tx perianal disease and in controlling crohns colitis, other ABT’s such as Cipro, Ampicillin, and Tetracycline effective in controlling CD ileitis, and ileocolitis. Immunosuppressive meds when unresponsive to other treatments. present such as canned fruits, vegetables and white bread Diverticulitis ** -Uncommon under 40yrs; risk rises after -Rare in pediatric; equal in men women -More common in developed countries -High in low fiber, high fat red meat diets
develop symptoms -LLQ abd pain, worsens after eating -Pain sometimes relieved with BM or flatus -BM may alternate between diarrhea constipation -LLQ abd tenderness with possible Firm, fixed mass may be identified in area of diverticula -May have rebound tenderness with guarding\rigidity -Tender rectal exam; stool usually + for occult blood -Abd x-ray can reveal free air, ileus, obstruction -Barium studies show sinus tracts, fistulas, obstruction -Colonoscopy to r\o Ca, but less sensitive than barium for diverticula -Asymptomatic cases managed with high fiber diet or fiber supplement with psyllium -Mild symptoms managed outpatient with clear liquid diet and rest -Atb should not be routinely used but can be with diverticula abscess culture -Increase fiber in diet to avoid constipation and straining -H2O intake of at least 8\8oz glasses to promote bowel regularity -Bulk-forming laxative may be needed Ex:psyllium,
diverticulitis,& number of diverticula which occur in sigmoid colon. discomfort -Fever, chills, tachy; LLQ with anorexia, N\V -Fistula may form causing dysuria, pneumaturia, fecaluria -CT with contrast (or) flagyl with bactrim -Symptoms usually subside quickly and diet can be advanced slowly -Pain managed with antispamotics Ex; Levsin, Bentyl, BuSpar -Avoid morphine -NG for ileus or intractable N\V -Pt can be D\C’d from hosp once able to maintain adequate nutrition\ hydration if acute phase resolved -Colon resection may be necessary if no improvement or deterioration after 72hrs of treatment Metamucil GERD ** -Can occur at any age -Risk increases with age, then decreases after 69yrs -Prevalence equal across gender, ethnic, cultural -Obesity, alcohol, caffeinated beverages, chocolate, fruit, -Heartburn; mild to severe -Regurgitation, water brash, dysphagia, sour taste in AM, belching, coughing, odynophagia (painful swallow), hoarseness or wheezing at night -Substernal retrosternal pain -Worsens if reclined -H&P usually normal -May be + for occult blood in stool -Usually Hx alone diagnoses -May manifest with atypical symptoms such as adult-onset asthma, chronic cough, chronic laryngitis, sore throat, noncardiac chest pain -8wk trial of PPI; weight loss, avoiding triggers -If unresponsive to once daily dosing; can increase to twice daily; if no relief EGD needed -PPI and H2-RA should not be taken together -Pt’s on long term therapy should be re- eval’d q6mos -Weight loss, med compliance and avoidance of triggers -Small frequent meals; main meal mid-day, avoid eating 4hrs before bed, avoid straining, sleep with HOB elevated, smoking cessation, stress mgmt
-If pt fails to
living in crowded conditions, no clean water source (nonfiltered water), smoking in abdomen. Abdominal pain that is worse when stomach is empty. Nausea/loss of appetite/unintentio nal weight loss. Frequent burping/bloating
RUQ/LUQ
tenderness assay -Urea breath Test -Biopsy with histologic al examinati on -Serological antibody therapy is clarithromycin and either amoxicillin or metronidazole with a PPI BID for 14 days. Amoxicillin preferred over metronidazole b/c there are some resistant strands of metronidazole.
(PUD)
-Medication side effects Irritable bowel syndrome ** Women more than men, rate 3:1; starts in late adolescence and early adulthood; rare in pts > -2 kinds of patients- those with abdominal pain and altered bowel habits, and those with painless diarrhea. -Left lower quadrant pain, sharp and burning with cramping or a diffuse, dull ache, precipitated by eating, stress and relieved with a bm or flatus. -The pain does not interfere with sleeping, frequent complaints of abdominal distention, gas, and belching, urgency to defecate, passage of large volumes The physical exam tenderness in LLQ and over the umbilicus or epigastric area in those with small bowel involvement. Digital rectal exam may reveal tenderness and may exacerbate symptoms. -No weight loss or deterioration in health. -Key to diagnosis is the lack of fever, leukocytosis, or bloody stools. pg579 advanced assessment
CBC, ESR, CMP
(electrolytes, serum amylase), urinalysis, stools for occult blood, ova and parasites, and cultures. Labs mostly normal and any diagnostic clue as to the cause is helpful. If WBC found in the stool = infectious or inflammator y process and not IBS. Rule out food intolerance, Producing IBS include caffeine, legumes (and other fermentable carbohydrates), and artificial sweeteners. alleviate symptoms by eating a lower-fat diet that contains more protein. High fiber diet is good, introduced slowly to avoid the sensation of bloating, 8 glasses of water per day, probiotic VSL#3 one packet bid, Antidiarrheal medications only temporary. -If diarrhea is severe, episodic use of loperamide (Imodium) 2 mg or diphenoxylate (Lomotil) 2.5–5.0 mg every 6 Recognize triggers and avoid them. Patients must understand that the goal of treatment is to improve their symptoms, not cure the disease, and that improvement in symptoms can be a time- consuming process. Dietary education- fiber intake increase
of mucus lactase deficiency (hydrogen breath hours
and 1/3 of those w/ gastric ulcers. endoscopy. Serology test or direct bacteriological analysis via an esophagogastr od uodenoscopy past 2 weeks, EGD considered. If used for ciprofloxacin, phenytoin due to it binding with these
-Nausea & anorexia sometimes occur in pts w/ gastric ulcers. Vomiting and weight loss indicate more serious complications like gastric malignancy or pyloric obstruction. Pts w/ duodenal ulcers may report a reduction in pain after eating; pts w/ gastric ulcers tend to experience more intense pain after eating. (EGD) Bx à to check for H. Pylori. EGD is ordered for pts who have failed the standard triple-drug therapy for H. Pylori. A serological antibody (enzyme- linked immunosorbe nt assay) test can be used detect infection w/ H. Pylori, doesn’t distinguish between active or past (treated) infection and is expensive. Urease is plentiful in pts w/ H.Pylori infection. Breath tests for H. Pylori are based on the production of ammonia from the metabolism of urea by urease à indicate active infection and are peptic ulcer tx, standard therapy is daily x 6 wks or half the dose bid x 8 weeks (cimetidine, ranitidine, nizatidine, famotidine) -Other agents: antacids were mainstay of ulcer treatment. Do not use antacids with calcium in PUD because calcium causes rebound acid secretion. Sucralfate 1g QID heals duodenal ulcers, bismuth (also has antimicrobial action against H. Pylori), misoprostol (Cytotec) used for prophylactic measure to prevent gastric ulcer formation in pts who use NSAIDs. Triple therapy for H. Pylori is a combination of 2 antibiotics (clarithromycin and either amoxicillin or metronidazole) w/ a PPI BID x 14 days. Amoxicillin preferred over metronidazole due to resistant h. pylori strains. Bismuth subsalicylate & 2 antibiotics is also meds.
fasting serum gastrin level should be drawn. Levels higher than 200 pg/mL should be confirmed on repeat testing and followed by basal and peak acid- output measurement s. Zollinger- Ellison syndrome should be suspected in pts whose fasting serum gastrin level is > 600 pg/mL and who have a basal acid output > 15 mmol/hr. Pancreatitis ACUTE \ CHRONIC ACUTE : About 80% of hosp admissionas are a result of biliary tract disease (passing gallstones) or alcoholism. --Risk: Infection (mumps), Hyperlipidemia, Metabolic disorders (hyperparathyroi ACUTE: Pain that is intense, abrupt onset deep epigastric pain that last for hours to days. Radiates straight through the back. Pain is often refractory to narcotics. Aggravated by vigorous activity (coughing) and lying supine. Alleviated when seated and ACUTE: Severe abdominal tenderness over epigastric area accompanied by guarding. Abdominal distension presents in about 20% of patients. Bowel sounds hypoactive or absent if paralytic ileus present. Tachycardia (100- 140 b/min) with
ACUTE:
Abdominal Pain Elevated Serum Amylase/Lipa se that return to normal after 3-7 days WBC between 12- 20, 000 CT of abdomen: ACUTE: Management is aimed at limiting severity of pancreatic inflammation, preventing further complications and managing symptoms. Mild symptoms can resolve on its own and managed outpatient conservatively. Fasting is necessary until symptoms have subsided.
ACUTE:
Informed the cause of pancreatitis Reduction of dietary intake of fat Abstain from alcohol abuse Drug induced-- avoid causing agent Hyperlipidemia--
dis m, hypercalcemia), Drugs (furosemide, valproic acid, sulfonamides, thiazides), leaning forward. Intractable nausea/vomiting. Depending on severity rapid, shallow respirations. Increased blood pressure due to pain. provides fast and accurate for definitive diagnosis Maintain fluid status with parenteral fluids Pain medication other than diet instruction and information on avoidance of factors such as alcohol,
