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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
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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