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Gastrointestinal Disorders: Symptoms, Diagnosis, and Treatment, Exams of Nursing

Detailed information on various gastrointestinal disorders, including their symptoms, diagnosis, and treatment. Topics covered include bacterial infections such as shigella and staphylococcus aureus, esophageal chest pain, irritable bowel syndrome, and abdominal pain causes. The document also discusses the order of abdominal examinations and the significance of various abdominal maneuvers.

Typology: Exams

2023/2024

Available from 04/07/2024

DREDWARD
DREDWARD 🇺🇸

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A nurse practitioner is caring for a 34-year-old man with a known history of intravenous drug use disorder and sexual intercourse with men. The patient presents to the clinic with a new onset of fatigue, ecchymosis, abdominal pain, and pruritus. The patient states that his symptoms have been present for the past month and are getting worse. On exam, the nurse practitioner notes the patient's sclerae are jaundiced. An enzyme-linked immunosorbent assay confirms a hepatitis C diagnosis. Which of the following is the best next step in treating hepatitis C? Determine if patient is eligible for simplified treatment Ledipasvir-sofosbuvir Metavir Recombinant immunoblot assay

Determine if patient is eligible for simplified treatment

The primary test used to diagnose hepatitis C infection is enzyme-linked immunosorbent assay. This test is also useful in diagnosing human immunodeficiency virus. The nurse practitioner should consider starting treatment at this time and determine if the patient is eligible for simplified treatment. There are several antiviral medications on the market to treat hepatitis C. However, treatment options are determined by the virus's serotype and degree of liver damage.

A previously healthy 62-year-old woman presents to your office with dizziness. For the past 2 weeks, she has been experiencing an occasional spinning sensation that lasts approximately 20-30 seconds. She first noticed it while tilting her head back in the shower and also had symptoms when rolling over in bed. Which of the following is the most likely diagnosis? Benign paroxysmal positional vertigo Labyrinthitis Ménière disease Orthostatic hypotension

Benign paroxysmal positional vertigo

When evaluating for stress urinary incontinence, which of the following tests should be performed to confirm the diagnosis? Bladder stress test Postvoid residual Urinalysis Urodynamic test

Bladder stress test

A 75-year-old man presents to the clinic to discuss concerns regarding cancer screening. His brother was recently diagnosed with esophageal cancer, and he believes that he is having similar symptoms to what his brother had a year ago. What are the most common symptoms of esophageal carcinoma to look for in this patient? Abdominal pain and food regurgitation Dysphagia and weight loss Hematemesis and odynophagia Hoarseness and diarrhea

Dysphagia and weight loss

Esophageal carcinoma is a relatively rare cancer, accounting for about 1% of all cancers in the United States. The incidence of esophageal carcinoma has remained stable over the last several decades. Esophageal carcinoma is about four times more likely to occur in men than women. The two main types of esophageal carcinoma are squamous cell carcinoma and adenocarcinoma, with the latter being the most common type. The most common symptoms of esophageal carcinoma are progressive dysphagia, odynophagia, and weight loss

A 60-year-old man presents for evaluation of an ongoing tremor. He notes the tremor has been present for roughly 1 year. He says it occurs in both hands, primarily with activity and most notably with writing and eating, and it appears to improve with alcohol intake. He has a medical history of well-controlled hypertension, hyperlipidemia, and benign prostatic hypertrophy. He reports his father had a similar tremor. On physical examination, the patient's vital signs are normal, and a rhythmic, moderate amplitude tremor is noted to the wrist and fingers when his hand is outstretched and with finger-nose testing. The tremor is absent at rest. There is no dysmetria with finger-nose testing, gait is normal, and there is no rigidity with passive movements of either arm. What is the likely diagnosis in this patient? Benign essential tremor Dystonic tremor Enhanced physiologic tremor Parkinson disease

Benign essential tremor

Benign essential tremor is the most common movement disorder in adults and typically involves the hands but can also affect the head or voice. The classic clinical feature is a tremor activated by movement or when the extremity is held in an outstretched posture against gravity. The tremor is

absent when the extremity is relaxed, and there are typically no other neurologic findings, such as bradykinesia, rigidity, or postural instability

A 45-year-old businessman presents for "shakiness" of his hands for several months. He notices it most when giving a presentation at work, and adds that his voice "quivers" at those times too. No other symptoms are present. He says his father had a similar problem for most of his adult life. Which of the following medications is the best initial selection for this condition? Botulinum toxin A Donepezil Propranolol Rasagiline

Propranolol

This patient is showing symptoms of benign essential (familial) tremor, for which the best initial treatment option in lifestyle-limiting disease is the beta-blocker propranolol. Essential tremor usually presents with a postural tremor of the hands or head that is often worsened by psychic stress

Which of the following physical examination findings is most consistent with a diagnosis of tension-type headache? Miosis Neck muscle tenderness Photophobia Vision loss

Neck muscle tenderness

Neck muscle tenderness is a physical examination finding commonly found in a patient with tension- type headache. Tension-type headache is the most common type of headache and one of the most common disorders in the world. It is described as a mild to moderate bilateral, non-pulsating head pain often characterized as dull or "band-like". The most common precipitating factor is stress followed by odors and hunger.

A 78-year-old man with a history of advanced liver cirrhosis presents to the clinic for a check-up. Which of the following findings would alert the provider to possible hepatorenal syndrome? Blood urea nitrogen of 20 mg/dL Creatinine of 3.02 mg/dL Urine protein of 54 mg/dL Urine RBC of 4/hpf

Creatinine of 3.02 mg/dL

Hepatorenal syndrome is associated with a poor prognosis and occurs in patients with advanced liver disease in which vasodilation and reduced cardiac output cause acute kidney injury. Patients most often affected have portal hypertension due to severe alcoholic hepatitis, cirrhosis, or metastatic tumors. Patients with ascites are most likely to develop hepatorenal syndrome

A 32-year-old woman reports burning with urination, frequency, urgency, and suprapubic pain for 3 days. She has no prior history of urinary tract infections and does not have any chronic health conditions. She reports no fever, chills, flank pain, or vomiting. On exam, there is no costovertebral angle tenderness. Her urinalysis is positive for leukocyte esterase and nitrites. What therapy should be prescribed? Amoxicillin 500 mg three times a day for seven days Ceftriaxone 500 mg intramuscularly once Levofloxacin 500 mg orally twice a day for seven days Nitrofurantoin 100 mg orally twice daily for five days

Nitrofurantoin 100 mg orally twice daily for five days

For uncomplicated cystitis, nitrofurantoin 100 mg orally twice daily for five days is an effective regimen with low rates of antibiotic resistance.

Osmotic diarrhea is one category of non-infectious diarrhea that occurs when fecal osmotic gap is over 125 mOsm/kg. What is one common cause of osmotic diarrhea? Excessive bile salts after cholecystectomy Microscopic colitis Small intestinal bacterial overgrowth Sugar substitutes such as sorbitol and sucralose

Sugar substitutes such as sorbitol and sucralose

In a patient with chronic abdominal pain, which additional finding suggests a diagnosis of irritable bowel syndrome? Decreased hemoglobin Improvement with defecation Nocturnal or progressive abdominal pain Weight loss

Improvement with defecation

Which of the following is correctly paired sensory or motor function testing of the hand? Median nerve motor, abduct index finger against resistance Median nerve sensory, two-point discrimination over the dorsal thumb Radial nerve sensory, two-point discrimination over the tip of the index finger Ulnar nerve sensory, two-point discrimination over the tip of the little finger

Ulnar nerve sensory, two-point discrimination over the tip of the little finger

The ulnar nerve provides innervation to forearm muscles and controls the intrinsic muscles of the hand while providing sensation to the little finger and the ulnar half of the ring finger.

A 44-year-old obese diabetic woman presents with episodes of right upper quadrant and epigastric abdominal pain after meals for the past month. The pain is constant and steady, peaking in about one hour. During this latest episode, the pain lasted seven hours and radiated to her right shoulder. On examination, she is tender in the right upper quadrant of the abdomen; deep palpation during

inspiration causes the patient to wince and pause to catch her breath. She also has fever and tachycardia, but no jaundice. Alkaline phosphatase, total bilirubin levels, and white blood cells are elevated. Aspartate aminotransferase, alanine aminotransferase, amylase, and lipase levels are slightly elevated. Which one of the following is your presumptive diagnosis? Acute cholecystitis Acute hepatitis Acute pancreatitis Peptic ulcer disease

Acute cholecystitis

Cholecystitis is inflammation of the gallbladder and can be either acute or chronic. Symptoms of biliary colic develop when gallstones temporarily block the cystic duct. Prolonged obstruction of the cystic duct can result in inflammation of the gallbladder wall. Risk factors for gallstones include pregnancy, female sex, obesity, weight loss, and oral contraceptive use. Risk factors for acalculous cholecystitis include diabetes, human immunodeficiency virus infection, total parenteral nutrition, or prolonged fasting. Acute cholecystitis presents with constant right upper quadrant pain lasting for hours associated with nausea, vomiting, and low-grade fever. On examination, patients may have epigastric or right upper quadrant tenderness and a positive Murphy sign, which is inspiratory arrest during deep palpation of the right upper abdominal quadrant.

A 35-year-old woman makes an appointment to establish primary care. Three months ago she was diagnosed with myasthenia gravis which is now only mildly symptomatic and is properly treated by a neurologist. Which of the following would you most expect to find during her intake physical examination? Hyporeflexia Ptosis Sensory abnormalities Weak hypothenar muscles

Ptosis

Myasthenia gravis (MG) is a disease of neuromuscular transmission characterized by fluctuating weakness and fatigability of certain muscles, namely those of the eyes, face and other cranial nerves. Pathological findings include a widened synaptic cleft, decreased surface area of the postsynaptic button, decreased number of postsynaptic acetylcholine receptors and the presence of anti- acetylcholine receptor antibodies. Symptoms typical of MG are drooping eyelids (ptosis), diplopia, strabismus, dysphonia, dysarthria and dysphagia. Electrodiagnostics are primarily used in confirming a diagnosis

Which viral etiology of hepatitis is most likely to result in chronic infection in adults? Hepatitis A Hepatitis B Hepatitis C Hepatitis D

Hepatitis C

An 80-year-old woman presents to the clinic to discuss the results of a barium esophagography that showed a bird beak distal esophagus. The patient continues to report difficulty with swallowing solids and liquids. Which of the following is the most likely explanation for these findings? Achalasia Esophageal rings Gastroesophageal reflux disease Mallory-Weiss syndrome

Achalasia

Achalasia is an esophageal motility disorder characterized by gradual dysphagia with solids and liquids and regurgitation of undigested food. It occurs due to nerve degeneration in the distal two-thirds of the esophagus resulting in loss of peristalsis and impaired relaxation of the lower esophageal sphincter.

A 59-year-old man with a history of type 2 diabetes mellitus, hypertension, and obesity presents to the community clinic with rust-colored urine. He is currently taking lisinopril-hydrochlorothiazide 40/25 mg daily, metformin 1,000 mg BID, and glyburide 10 mg daily. He reports that he was feeling sick with a sore throat and fever 2 weeks ago after visiting his 12-year-old nephew. The rust-colored urine started yesterday morning. His vital signs are within normal limits except for a blood pressure of 162/96 mm Hg. On examination, he has 2+ pitting edema of his calves bilaterally, which was not present at his previous visit 2 months ago. Urinalysis reveals hematuria and mild proteinuria. Which of the following laboratory tests should be ordered to support the suspected diagnosis? Antinuclear antibody Antistreptolysin O Blood culture Creatine kinase

Antistreptolysin O

Poststreptococcal glomerulonephritis (PSGN) is an immune complex-mediated condition caused by nephritogenic strains of group A beta-hemolytic Streptococcus (GAS). The pathophysiology involves a type III hypersensitivity reaction in which immune complexes are deposited in the glomeruli, triggering complement activation and inflammation. PSGN typically presents 1-3 weeks after GAS pharyngitis or 3-6 weeks after GAS skin infection. Children 5-12 years old and adults ≥ 60 years old are most commonly affected. The clinical presentation ranges from asymptomatic, microscopic hematuria to gross hematuria, edema, hypertension, and proteinuria. In addition to hematuria and proteinuria, laboratory findings indicative of PSGN include elevated SCr, elevated blood urea nitrogen (BUN), low complement C3, and positive antistreptolysin O (ASO)

A 70-year-old man presents to the clinic for follow-up on his diabetes mellitus and chronic kidney disease. The provider orders a basic metabolic panel. Which of the following laboratory findings is consistent with stage 3 chronic kidney disease? Glomerular filtration rate 10 mL/min Glomerular filtration rate 20 mL/min

Glomerular filtration rate 50 mL/min Glomerular filtration rate 60 mL/min

Glomerular filtration rate 50 mL/min

Which of the following patients would be at the highest risk to develop a urinary tract infection in the first year of life? A Black female infant A circumcised male infant A White female infant An uncircumcised male infant

An uncircumcised male infant

Urinary tract infections are a common issue seen in infancy and childhood. Many factors put infants at risk for urinary tract infections, including age, circumcision status, sex, and genetics. Uncircumcised male infants are at the highest risk of developing a urinary tract infection, especially those under 1 year of age

A 61-year-old man presents with loss of appetite, unintentional weight loss, and dyspepsia. Endoscopy shows a gastric mass at the curvature of the stomach, and he is diagnosed with gastric carcinoma. Which of the following is true about his condition? Chemotherapy and radiation are standard initial therapy for localized disease Men have a higher risk of developing this condition The 5-year survival rate of advanced disease is 80% White individuals are more likely to develop this condition

Men have a higher risk of developing this condition

The most common type of gastric cancer is adenocarcinoma. Men develop this condition two times as often as women. Other risk factors for the development of gastric cancer include smoking, persistent Helicobacter pylori exposure, long-term ingestion of foods with nitrates, and the presence of certain types of gastric polyps, such as adenomatous and hyperplastic. Symptoms of this condition usually do not occur early in the disease. Patients may report abdominal pain, loss of appetite, nausea, difficulty swallowing, and unintentional weight loss as the tumor advances. Iron deficiency anemia and occult blood in the stool may be found.

A 75-year-old man with a history of hypertension, diabetes, hyperlipidemia, and chronic kidney disease (CKD) stage 3 presents to the clinic for an annual exam. His recent laboratory studies show creatinine 1. mg/dL and eGFR 20 mL/min/1.73m2 but are otherwise unremarkable. Which of the following events would explain the laboratory findings? Increase in ibuprofen over the last year Initiation of empagliflozin 3 months ago for diabetes Initiation of lisinopril 6 months ago for hypertension Reduction in furosemide dosage

Increase in ibuprofen over the last year

A 3-day-old male infant born at 39 weeks gestation presents to the clinic with his mother. The infant appears healthy and well-nourished. However, the clinician appreciates a yellow-orange discoloration of his face. The infant has no risk factors for hyperbilirubinemia neurotoxicity. How should this condition be managed? Admit him to the hospital for phototherapy Perform rebound bilirubin testing Promote breastfeeding 8-12 times per day Recommend supplement feedings with an iron-fortified formula

Promote breastfeeding 8-12 times per day

The clinician should promote breastfeeding 8-12 times per day because it enhances bilirubin excretion. Pathologic jaundice is when jaundice occurs too early (i.e., within the first 24 hours of life), continues too long (i.e., > 10-14 days), or involves bilirubin levels that are ≥ 30 mg/dL.

An 8-year-old girl is diagnosed with childhood absence epilepsy. Which of the following is the first-line pharmacologic treatment for this type of seizure disorder?

Ethosuximide Gabapentin Phenobarbital Valproate

Ethosuximide

First-line treatment for childhood absence epilepsy is ethosuximide 250 mg twice daily for children over the age of six, and 5 to 10 mg/kg/day divided in children under six.

While reviewing the medical history of a 16-year-old girl, you notice that she has had mildly elevated bilirubin levels in the past 2 to 3 years when she has had bloodwork done. Her complete blood count, blood smear, reticulocyte count, plasma aminotransferases, and alkaline phosphatase levels have all been normal. The patient has never had jaundice with any of these episodes. Family history reveals that her mother has a history of elevated bilirubin with illnesses. Which of the following is the most likely diagnosis? Crigler-Najjar syndrome Gilbert syndrome Hereditary spherocytosis Sickle cell disease

Gilbert syndrome

Gilbert syndrome is a benign condition that causes increases in unconjugated bilirubin due to a defect in a specific enzyme that acts to conjugate bilirubin. Gilbert syndrome is found within families, although it may occur in individuals as well. This syndrome is thought to affect 4-16% of individuals, depending on the population. Often, patients present with a mildly elevated total bilirubin while all other lab indices are completely normal

In which of the following ways does essential tremor differ from the tremor of Parkinson disease? Essential tremor can be treated with dopamine agonists Essential tremor is a pill-rolling tremor Essential tremor is exacerbated by action Essential tremor is unilateral

Essential tremor is exacerbated by action

Essential tremor is usually symmetric and exacerbated by action, whereas the tremor of Parkinson disease is usually asymmetric and occurs at rest. Essential tremor affects up to 5% of the general population after the age of 60. It is often inherited in an autosomal dominant fashion.

A 10-year-old girl presents with a history of chronic migraine, in which lifestyle measures and acute therapies have not been effective. The provider is considering starting the patient on a preventative agent. The patient is underweight with a BMI in the third percentile, has a history of asthma, and a family history of prolonged QT syndrome. The patient is also unable to swallow pills. Which of the following preventative medications would be the best to prescribe? Amitriptyline Cyproheptadine Propranolol Topiramate

Cyproheptadine

Chronic migraines are defined as headache that occurs on 15 days or more a month for more than three months, with eight of those days having typical migraine features as described above. Cyproheptadine, an antihistamine and serotonin antagonist with anticholinergic and calcium channel blocking properties, is a commonly used migraine preventative medication. It is usually prescribed at 2 to 16 mg per day,

What are the most common organisms that cause Acute Gastroenteritis and other associated conditions?

Clostridium Perfringens, E Coli, Salmonella, Shigella, S Aureus

Clostridium Perfringens gastroenteritis

Found in human and animal feces and in soil Meats most frequently contaminated, namely beef, poultry, and mexican style foods Incubation period 12-24 hours No WBCs in stool No Tx recommended, not transmitted from person to person

Salmonella gastroenteritis

Food/animal origin most commonly from poultry, eggs, un-pasteurized milk Incubation 12-48hrs, usually < 24hrs Watery diarrrhea, occult and gross blood with WBCs in stool Most likely kids < 5 and Adults > 70

Tx Salmonella Gastroenteritis

None unless evidence of systemic disease -> Fluoroquinolone, Bactrim, or Chloramphenicol

E Coli gastroenteritis

Food or water contaminated with human or animal feces Most common cause of "Travelers Diarrhea" Incubation 10hrs to 6 days, usually 24-48hrs Watery diarrhea -> Toxin promotes fluid secretion in small bowel which stimulates watery diarrhea Usually no WBCs in stool No Tx, ABX no evidence of usefulness

Shigella enteritis

Contaminated food or water; Also from homosexual transmission due to feces of infected humans Incubation 12-48hrs Fever, ABD pain, Watery diarrhea, occult and gross blood, WBCs stool Problem in childcare centers Tx: Same as salmonella

S Aureus gastroenteritis

Food products ham, poultry, filled pastries, egg/potato salads Incubation very short 30minutes to 8hrs; Usually 2-8 hours Soft stool, abrupt onset

What symptoms of gastroenteritis warrant a follow-up visit

If ABX therapy was indicated, fever, s/s > 3 days, protracted vomiting If s/s > 3 days with blood diarrhea -> Colitis If s/s > 3 days with pain and intermittent non-bloody stool -> Crohn's

Two types of Dysphagia

Oropharyngeal: difficulty with initiation of swallow Esophageal: Difficulty transporting down esophagus

Primary causes of dysphagia

Carcinoma, achalasia (Stricture of lower esophageal sphincter with dilation above), diffuse esophageal spasm (Nutcracked esophagus), decreased esophageal motility

Secondary causes of dysphagia

Reflux esophagitis, scleroderma, polymyositis, globus hystericus

What percent of people with normal cardiac caths have esophageal abnormalities?

50%

Causes of esophageal chest pain

Stimulation of esophageal chemoreceptors by acid reflux, smooth muscle spasm, or esophageal distention Motility disorders and GERD

GERD

Burning substernal pain that radiates upward Chest pain (Anginal in nature) Hoarseness, cough, wheezing, sore throat 2 factors: A low basal LES pressure and transient LES relaxation unassociated with a swallow (Latter most common)

GERD Tx

Therapeutic trial of antacids, PPI, or H2 receptor antagonists along with lifestyle modifications

GERD Dx

Patients with s/s > 10yrs, esp if over 50, early endoscopy d/t higher prevalence of Barrett esophagus (If present should do biopsy) Barium swallow simplest, shows presence of mucosal irregs, stricture, or esophageal ulcer

Hiatal Hernia

Herniation in part of the stomach through the diaphragm, through the normal esophageal hiatus into the thorax More common in women, elderly people Large hernia (>5cm) may cause s/s

Peptic Ulcer Disease

Duodenal and gastric ulcer Dudodenal ulcers: Usually located in duodenal bulb; No risk of cancer Gastric ulcers: Located in the lesser curvature, junction of body, and antrum of stomach; 1-3% are malignant

Duodenal Ulcer

Chronic if untreated; More common in younger patients 50-90% have recurrence if currative therapy not enacted 95% CAUSED BY H PYLORI Imbalance btwn normal duodenal defense and amount of stomach acid delivered to the duodenum from stomach Distress 1-3 hours after meal, relieved by food, antacids, vomiting. Minimal pain before breakfast Weight gain

Gastric Ulcer

Requires injury to gastric mucosal barrier and presence of some acid Most NSAID related, esp > 60 Weight loss

H Pylori

Most comon and important factor for duodenal ulcer Gram - Person to person spread Iron deficiency Tx: PPI Based triple therapy; Amoxicillin and Clarithromycin, flagyl if PCN allergy; 7-14 days of tx with PPI BID

What tests can you use to diagnose ulcers

Endoscopy: Can do with biopsy to detect H Pylori and r/o malignancy Serology test and urea breath test (H Pylori) FOB

Dyspepsia

Persistent epigastric discomfort Associated with IBS, cholelithiasis, GERD, chronic pancreatic disease

Irritable Bowel Syndrome

Chronic ABD pain and change in frequency or character of bowel movements without clear cause Present for at least 12 non-consecutive weeks (ROME criteria) over previous 12 months with at least 2 features of: ABD pain relieved with defecation, pain associated with change in stool frequency, pain associated with change in stool consistency Typically develop in late teens to early 20s

IBS Clinical Presentation

Cramping in mid to lower ABD (Usually LLQ) discomfort 1-2 hrs after meal and relieved by BM ABD distention, mucous stools, incompleted evacuation sensation

IBS Tx

Constipation: Tx with meds when dietary changes fail; Lactulose, Misoprostol, erythromycin Diarrhea: Loperamide ABD pain: Antispasmodics (Bentyl) Bloating: Simethicone, enzyme replacements

Inflammatory Bowel Disease

Group of lower GI disorders that cause inflammation and/or ulceration of bowel lining Crohns: Involves entire GI tract with discontinuous focal ulceration, fistula formation, and perianal involvement Ulcerative Colitis: Shallow, continuous inflammation, extending from rectum proximally to entire colon

Complications of IBD's

Vitamin Deficiencies: B12, iron, folate Depression/Drug dependence or addiction Protein and albumin malnutrition Hospitalization/Home IV TPN if severe

Medications for IBD

Sulfasalazine Olsalazine Mesalamine (Asacol) ABX: Flagyl alone or with Cipro Corticosteroids Immunosuppressants: Imuran, methotrexate, cyclosporine

Main differences between IBS and IBD

IBS often has alternating constipation and diarrhea with relief after evacuation of stool IBD tends to have extraintestinal signs including fever, weight loss

GI Bleeding testing

Hemoccult test: Laxatives increase numbers of true positive and false positive results High bulk diet severe days before stool test and take two different samples from three different stools over 3 days every year in patients older than 40 For 3 days before test avoid raw red meat (False positive), high doses of vitamin C, and ASA or NSAIDs

Causes of occult bleeding

Chronic, slow bleeding Gastritis, PUD, CA

Causes of melena

Black tarry stools PUD, gastritis, esophageal varices, CA

Causes of Hematochezia

Bright red blood in stool Diverticulosis, CA, hemorrhoids

General Guidelines for Lower GI tract bleeding

Patients < 50yo less likely to have lesion Do not perform lower endoscopys in patients with suspected diverticulitis or appendicitis d/t risk of perf Hematochezia -> Procto sigmoidoscopy first test then barium enema or colonoscopy Occult fecal blood and no symptoms -> Colonoscopy or sigmoidoscopy plus barium enema Barium enema detects colonic lesions

Polyps of colon

Lesions that bleed; GI bleed or change in bowel habits could signify presence All cancers of colon arise from types of polyps

Colorectal CA stats

Third leading cause of CA death 2/3 in people 66yrs or older High fat, low fiber diet predispose 1/2 detected with sigmoidoscope, other half colonoscope Polyps, familial polyposis, ulcerative colitis main predisposing conditions

Colorectal CA screening guidelines

Beginning at age 45 (New guidelines) for colonoscopy; Depending on findings every 1, 3, 5, or 10 year follow up Annual FOB or fecal immunochemical test (FIT)

What medications can cause diarrhea

Mg++, antihypertensives, NSAIDs, PPIs, SSRIs, ABXs, theophyllines, and chemo agents

Diarrhea

Increase in the frequency and fluid volume of BM Usually benign and self-limiting < 1wk If persists > 72hrs, or if gross blood in stool, needs evaluation (Stool for blood, leukocytes, pathogens) Sudden onset of loose, watery stool most commonly caused by infectious process (Bacterial vs Viral)

Antidiarrheals

Fluid and electrolyte replacement Absorbents: Kaopectate and bismuth salts (Pepto-Bismol) Opioid derivatives: Loperamide, Lomotil for chronic diarrhea

Order of abdominal PE

Inspect, Auscultate, Percuss, Palpate

Definitions and uses of these ABD maneuvers: Cullens Murphy's Markles McBurneys Succession splash Nikolsky's Blumberg's

Cullen's: Periumbillical bruising in pancreatitis Murphy's: Inspiratory apnea with palpation of gallbladder in RUQ

Markle's sign: Pain in RLQ when hell-drop test performed (Dropping to heels from standing on toes); Sign of localized peritonitis due to acute appendicitis McBurneys: Point of maximal tenderness in RLQ with appendicitis Succession splash: Sloshing sound heard in ABD when gently shaken which indicates delayed gastric emptying Nikolsky's sign: Skin finding where top layers of skin slip away from lower layers when rubbed; sign of staph infection Blumberg's sign: Rebound tenderness

Causes of diffuse ABD pain

Early ectopic pregnancy, IBS, gastroenteritis, mesenteric thrombosis, sickle cell crisis, IBD, obstruction

Causes of LUQ pain

Gastric ulcer, spleen, renal pain, gastritis, duodenal ulcer, PID

Causes of LLQ pain

Diverticulitis, ovarian pain, hernia, endometriosis

Causes of epigastric pain

PUD, GERD, Esophageal disturbances, aortic aneurysm, MI

Constipation

Fewer than 3 BMs/wk Infrequent, difficult passage of stool Usually result of motility disorder PE rarely helpful unless thyroid/ABD mass found

Constipation Tx

20-30g fiber/day, 64-80oz water/day Laxatives

Diverticular diseases

Diverticulosis: Presence of clonic diverticula without presuming accompanying s/s Symptomatic Diverticular disease: Pain and altered bowel habits in absence of evidence of diverticular inflammation DIverticulitis: Inflammation of one or more diverticula implying perforation of diverticulum

Large # patients asymptomatic; correlation with age

Diverticulitis

Most common complication of diverticulosis Perforation of diverticula s/s: ABD pain (LLQ most common), fever, n/v

May find urinary tract s/s if fistula Almost ALWAYS has leukocytosis and most require hospitalization during episodes

Cholecystitis

inflammation of the gallbladder; usually associated with gallstones Hallmark ABD pain (epigastric->RUQ within few hrs) and Murphys sign Begins abruptly within 1-3hrs after eating and subsides within 2-3 hrs after begins Acute: Most likely from stone

Preferred test for acute cholecystitis

Biliary scintigraphy (HIDA scan)

Cardinal signs of appendicitis

Pain that starts in the epigastrum/periumbilicus Migration of pain to RUQ (McBurneys) ABD rigidity

Additional s/s present with appendicits

Will often have fever and leukocytosis (70-90%) +Obturator: Passive rotation R leg with flexed knee eliciting pain +Psoas: Pain with raising straightened right leg against resistance

Tests to dx appendicits

CT most useful US in kids

Hemorrhoids

Unknown cause; current thought it distal displacement of anal cushions Constipation, internal pressure, low fiber diet contributing factors If thrombosed will have excuciating pain s/s: Pain (usually from fissure), pruritis, intermittent bleeding, prolapse) Usually have sponataneous resolution

Hemorrhoid tx

Conservative management: symptom relief with topical analgesics, minimize constipation Refer to surgeon when in doubt of dx or if no response within 3-4wks of conservative therapy or if pain is severe/evidence of strangulation

Hernia

Protrusion of a viscous part of body from its normal location Involve anatomical defects in ABD wall Inguinal, femoral, umbilical, previous surgical sites

What are the two terms for hernia displacement

Reducible: Can be pushed back into ABD cavity -> Non-emergent Incarcerated: Cannot be pushed back -> Chance of strangulation-

Inguinal hernias

75% of all ABD hernias Direct: Portions of bowel or omentum protrude directly through floor of inguinal canal Indirect: Enter inguinal canal through internal ring, may extend into scrotum Both types cause dull ache in groin and a bulge

Femoral hernias

Protusion of omentum or bowel into femoral canal More common in women 20% of hernias incarcerate Differentiated from lymph node and lipoma as they are not reducible

Umbilical hernias

Protrusion of omentum or bowel through umbilical ring Common in middle age women, cirrhotic patients (With ascites), obesity, pregnancy, and frail elderly patients

Incisional hernia

Common in obese, chronic renal failure patients, and with wound infection Commonly treated with mesh

Acute vs Chronic hepatitis

Chronic hepatitis is unresolved disease for > 6 months Acute usually self-limiting

which hepatitis virus(es) are transmitted by fecal-oral route?

A

S/S hepatitis

Symptoms similar across all types Fatigue, nausea, flu-like ABD s/s N/V/D 70% have palpable liver Jaundice first few days then decreases completely within 2-8 wks after onset Posterior cervical lymphadenopathy and splenomegaly

What are the criteria for a complicated UTI

Hx of childhood UTIs, immunocompromised, preadolescent, or postmenopausal, pregnant, underlying metabolic disorder, urologic abnormalities, male gender and anatomy

What features on a UA would indicate UTI

Leukocytes, Nitrates Presence of bacteria, RBCs

Tx Uncomplicated UTI

nitrofurantoin 5 days (dont use in CKD) trimethoprim-sulfamethoxazole 3 days 95% effective Full 7-10 day course should be used in complicated cases

S/S Pyelonephritis

UTI symptoms with flank pain, CVA tenderness, fever, chills, urinary frequency/hesitancy May have large amounts of proteinuria

Hematuria

3 RBCs on high power field on microscopic evaluation of urinary sediment Gross hematuria or hematuria associated with proteinuria/pyuria highly predictive of significant disease Requires 2-3 urinary samples to develop conclusion Gross hematuria requires urology referral

What can cause false hematuria

Menses, beats, certain medications (Analgesics, antimicrobials, diuretics)

What can cause hematuria

Vigorous exercise, sickle cell, pyelonephritis, polycystic kidneys, lupus, kidney stones, BPH, prostatitis, blood thinners, trauma, fever

What causes hematuria with pyuria

Most likely infectious, consider STDs TB rare cause of hematuria

What causes hematuria with proteinuria and RBC casts

Glomerulonephritis Proteinuria > 2g/24hrs

Proteinuria

150mg protein /24hrs Increased risk of cardiovascular mortality with chronic proteinuria Often transient finding Treatment based on cause

Screening for proteinuria

Patients with prior urologic hx and previous positive protein screening Patients with foaming of urine Diabetic

Polycystic kidneys HTN Pts with proteinuria with other comorbids

Chronic Kidney Disease

Reduction in kidney function for > 3 months Broken down into stages

3 Major Complications

Renal osteodystrophy, Nutritional Disturbances, Inflammation Hyperparathyroidism also may be present

What type of pain do kidney stones produce

Colicky. Intermittent building pain progressing in waves

What are most kidney stones made of

80% calcium oxalate (CaOx) mixed with calcium phosphate

Non-pharm treatments for kidney stones

Fluid intake 2-3L water/day adequate for most patients Stones smaller than 5mm likely to pass on their own

Pharm treatments for kidney stones

Medical expulsive therapy with alpha adrenergic blockers (Tamsulosin) or CCBs can increase chance of passage Pain control with NSAIDs or narcotics Avoid NSAIDs if planning lithotripsy d/t increased risk of perinephric bleeding

What are the five types of incontinence

Stress, Urge, Mixed, Overflow, Functional

Stress Incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing Most common in women R/t Sphincter incompetence from uretheral hypermobility or sphincter damage

Urge Incontinence

Incontinence in response to a sudden, urgent need to void; the person cannot get to a toilet in time Commonly from detrusor hyperactivity resulting from uninhibited contractions (Cystitis, stone, tumor)

Mixed incontinence

the combination of stress incontinence and urge incontinence

Overflow Incontinence

involuntary loss of urine associated with overdistention and overflow of the bladder Commonly from outlet obstructions such as BPH, tumor, stricture, or medications Also can result from neurogenic bladder from DM, ETOH, disc disease

Functional incontinence

urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, or cognitive deficits

What is a universal treatment for incontinence

Behavioral therapy, bladder training, pelvic floor exercises

Difference between lower motor neuron and upper motor neuron neurogenic bladder

Lower: Failure to empty; Large areflexic, flaccid bladder. Spastic sphincter Upper: Failure to store; Small, overactive, spastic bladder Urology referral for both

Where is the detrusor innervated

L1-L Injury below is lower neuron

Interstitial cystitis/Bladder Pain syndrome

Chronic inflammatory condition consisting of bladder pain, urgency, frequency, and nocturia in absence of other disease Majority of cases in women Symptoms wax and wane for months or years Frequency can be up to 60x/24hrs

Tx for IC/BPS

First line: All patients; Education on self-care practices and behavioral modifications, implement stress management practices Second-line: Manual physical therapy techniques, multimodal pain management approaches; Meds: Amitryptline, cimetidine, hydroxyzine, or pentosan polysulfate

Most common pathogen for community acquired UTI in asymptomatic women during reproductive years

E Coli

Pharmacological intervention for patients with urge incontinence includes:

Anticholinergics

oxybutynin, toleterodine, fesoterodine

The urinary sediment finding indicative of pyelonephritis

White blood cell casts

What is a CT head superior to MRI in identifying

Calcification and hemorrhage

Why is MRI the preferred imaging for most CNS diseases

Visualizes the spinal cord, reveals more pathologic changes Identifies tumors, infarcts, AVMs/aneurysms, abscesses, MS,

What are the primary headache types

Tension, cluster, migraine

What kind of cause is most common in new onset HA in elderly pt

Secondary: Tumor, bleed, etc

HA Assessment key points

Aggravating/Alleviating factors Associated neurologic s/s: Spots before eyes, photophobia, N/V, focal numbness or weakness or vertigo, scalp tenderness, motion sickness (Children)

HA Red Flags

Exertion induced "Worst Headache ever" Seizures; Systemic illness Strong patient or family concerns (Anxiety, feeling of doom) Family hx brain tumors or aneurysms Age < 5 or > 50

Tension HA

Most common type Unknown MoA; Lasts 30min-7days At least two of following: Pressing/tightening (non-pulsating) band like quality, mild or moderate intensity, bilateral, not aggravated by exertion

Tension HA Tx

OTC analgesics (NSAIDs/Tylenol) Alternative therapy: Massage, chiropractic, acupuncture Pharm tx only if other tx failed: Codeine, propoxyphene, analgesic/sedative/caffiene combos TCAs shown to help severe chronic

Migraine general characteristics

Attacks last 4-72hrs; Can last weeks Pain is pounding/throbbing Photophobia, Phonophobia, N/V common findings during Need 2/4 of these findings: Moderate/Severe intensity, Pulsating quality, Worsens with exertion, Primarily unilateral

Migraine with aura

At least 3/4 characteristics must be present: One or more fully reversible aura symptoms indicating focal cortical or brain stem dysfunction at least one symptom that develops over 4 or more minutes or two symptoms in succession No aura symptoms lasts > 60 minutes (More symptoms timeline increased) HA follows aura with free interval < 60 min

Typical Migraine Auras

Homonymous visual disturbance Unilateral paresthesia or weakness Aphasia or unclassified speech difficulty Fortification hallunications (Slowly enlarging scotomata surrounded by luminous angles

Migraine Tx (episodic)

Mild: NSAIDs, Tylenol, ASA Mod-Severe: Triptans, DHE, Alpha-2 agonists, anti-epileptics, TCAs, beta blockers, CCBs, botox

Triptan considerations

Constrict etracerebral intracranial vessels and inhibit activity in peripheral trigeminal ganglion Cannot use with ergotamine within 24hr period 10% reduction in coronary artery diameter; Contraindicated CAD and ischemic cerebrovascular disease Risk evaluation should be considered with 2 or more of smoking, HTN, LDL > 159 orHDL < 40, and Men

45 or women > 55

Ergotamine considerations

Category X medication, do not use if pregnant or breastfeeding Serotonin receptor agonist Most cost effective first choice

When to use HA preventative medications

or = 2 attacks/month with associated disability OR less frequent attacks that cannot be controlled with therapy (Acute meds > 2x/wk) and disrupt life Or comorbid disease

Migraine prophylaxis

TCAs SSRIs: Standard doses Beta blockers: Propanolol first choice, Nadolol, atenolol

Verapamil Divalproex, Topiramate, Gabapentin Mg++, B2, Botox

What symptoms would someone have who has a HA associated with increased ICP

Pain worst in the morning upon waking up (Swelling more predominant)

What guiding thoughts should be implemented for treatment of all HA's?

Alleviate/remove precipitating factors if any (Foods, PMS, birth control, vasodilators, ETOH, irregular sleep) Initiate Tx at lowest effective dose Give each med fair trial (May be 3 mo) If multiple issues, choose med that can treat both (Carbamazepine for epilepsy and migraines, propanolol for tachycardia and migraines etc)

Cluster HA

Severe, unilateral orbital, supraorbital, or temporal pain lasting 15-180min Associated with conjunctival injection, facial sweating, lacrimation, miosis, congestions, ptosis, rhinorrhea, eyelid edema Frequency up to 8x daily or every other day More common in men and ETOH use

Cluster HA Tx

100% O2 with prednisone Can use sumatriptan Prophylactic meds if uncontrolled (Verap, propan, TCA, lithium)

What is considered a diagnosis of epilepsy

Two spontaneous seizures in lifetime without other identifiable cause

Seizure prognosis (Risk rate)

After first unprovoked seizure risk of recurrence at 3-5yrs 40% Adults who have recurrence of tonic-clonic seizures have 60% recurrence in first year and 70% by 3 yrs

Tx Epilepsy

Cannot be cured Refer to neurologist for work up Valproate if generalized seizures

What is considered vertigo

Any illusion of movement Dizziness does NOT have illusion of movement

A 35-year-old man with a history of human immunodeficiency virus presents to your office with complaints of urinary symptoms, chills and muscle aches. Physical exam findings include a temperature of 102.1F, pain to palpation of the suprapubic area, and a warm, firm, exquisitely tender prostate on rectal exam. Which of the following is the most appropriate therapy? Abacavir Nitrofurantoin Tamsulosin Trimethoprim-sulfamethoxazole

Trimethoprim-sulfamethoxazole

Acute bacterial prostatitis occurs when microorganisms enter the prostate gland through the urethra. Prostatitis often presents in the primary care setting among young and middle-aged men, however bacterial prostatitis is relatively uncommon. Risk factors include conditions that predispose men to urogenital infections such as anatomical anomalies and urogenital instrumentation. Lower urinary tract symptoms including prostatitis occur more frequently in men with human immunodeficiency virus (HIV). First-line treatment is with trimethoprim-sulfamethoxazole or a fluoroquinolone such as ciprofloxacin or levofloxacin. Acute Bacterial Prostatitis Sx: fever, chills, perineal or pelvic pain, and dysuria PE: boggy and exquisitely tender prostate Most common causes< 35 years old: N. gonorrhoeae, C. trachomatis> 35 years old: E. coli Treatment< 35 years old: ceftriaxone IM and doxycycline

35 years old: fluoroquinolone or TMP-SMX for 4 weeks

A 60-year-old man with a history of hypertension and type 2 diabetes mellitus presents to your office for his annual exam. He reports nonadherence with his routine medications and has been taking ibuprofen daily for the past 6 months due to headaches. His current medications include losartan 50 mg daily, metformin 1,000 mg twice daily, and insulin glargine 20 units at bedtime. Vital signs today are a blood pressure of 150/90 mm Hg, heart rate of 80 bpm, respiratory rate of 16 breaths/minute, and temperature of 98.6°F (37°C). Laboratory results reveal a creatinine of 1.8 mg/dL, estimated glomerular filtration rate of 45 mL/min/1.73m2, and urinalysis showing 2+ proteinuria and hematuria. Which of the following is the most useful initial imaging study to evaluate this patient for chronic kidney disease? Abdominal X-ray CT scan with contrast CT scan without contrast Kidney ultrasound MRI

Kidney ultrasound

Ultrasound is the most useful imaging study to confirm that both kidneys are present and symmetric and to estimate their size. It can also determine whether a mass or obstruction is present. Bilateral small-sized kidneys indicate a diagnosis of long-standing CKD, and kidneys may be of normal size with either acute or subacute kidney disease.

A 28-year-old man presents to the clinic due to progressive dysphagia and burning epigastric pain over the past 2 months. He previously tried famotidine and omeprazole for symptoms of acid reflux but experienced no relief. He has dysphagia to solid foods but can swallow liquids without difficulty. He has a history of moderate persistent asthma for which he takes combination budesonide-formoterol and albuterol. His mother has celiac disease, and his father has type 2 diabetes mellitus. The patient is not sexually active and does not use tobacco, drink alcohol, or use recreational drugs. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most likely diagnosis? Barrett esophagus Eosinophilic esophagitis Esophageal adenocarcinoma Viral esophagitis

Eosinophilic esophagitis

This patient's presentation is consistent with eosinophilic esophagitis, a chronic immune-mediated inflammatory condition characterized by dysphagia primarily to solids and a history of atopic disease (e.g., asthma, allergic rhinitis, atopic dermatitis). The most common symptom of eosinophilic esophagitis is dysphagia to solid foods. Management options for eosinophilic esophagitis may include dietary changes to limit exposure to allergens, acid suppression therapy, and topical glucocorticoids.

Which lab marker elevation has the highest positive predictive value for a biliary etiology in patients diagnosed with acute pancreatitis? Alanine aminotransferase Alkaline phosphatase Lipase Total bilirubin

Alanine aminotransferase

Elevation in liver enzymes may result from biliary-induced pancreatitis. Alanine aminotransferase (ALT) has a high specificity/positive predictive value for a biliary etiology of pancreatitis. Levels three times greater than baseline support the diagnosis of biliary pancreatitis. The higher the level of ALT, the greater the specificity and predictive value for gallstones. ALT levels more than 150 IU/L have 96% specificity and 95% positive predictive value for gallstone pancreatitis.

Which of the following is a risk factor associated with the development of pancreatic cancer? Alcohol consumption Cigarette smoking Diet high in red meats Sedentary lifestyle

Cigarette smoking

Cigarette smoking has been associated with 20 to 25 percent of all pancreatic cancers. It is the most common environmental and preventable risk factor associated with the disease. Other risk factors include genetic predisposition, chronic pancreatitis, and longstanding diabetes. Pancreatic cancer is the