Exam 3 Flashcards
Red flags for abdominal pain
fever, chills, leukocytosis with increases neutrophils and bands on the differential, and rebound tenderness
Abdominal pain lasting >6 hours or the pain wakes up the patient at night
New onset constipation >50 years old
RUQ pain
cholecystitis, RLL pneumonia, acute hepatitis
LUQ pain
Gastritis, pancreatitis, MI, LLL pneumonia
RLQ pain
Appendicitis, ectopic pregnancy, ovarian cyst, diverticulitis, endometriosis
LLQ pain
Diverticulitis
GI imaging for plain flat/upright
Ileus, bowel obstruction, perforation
GI imaging fo abdominal US
gallbladder, pelvic organs, appendix, kidneys, liver
GI imaging CT
Acute abdominal pain, diverticulitis
GI imaging MRI
Hepatocellular carcinoma, metastatic disease
GI imaging EGD
Upper GI
GI imaging colonoscopy
Lower GI
Lower abdominal pain in females
Can indicate gynecologic problem–ovarian cyst, ectopic pregnancy
Causes of acute abdominal pain
Appendicits, cholecystitis, diverticulitis, small bowel obstruction, perforated peptic ulcer, peritonitis, ruptured ectopic pregnancy, PID, ruptured AAA, hypercalcemia, superior mesenteric artery syndrome, acute intermittent porphyria
3 s/s most predictive of acute appendicitis
Pain that starts in the epigastrium or periumbilical area, migration of the pain to the RLQ, and abdominal rigidity
McBurney point
Appendicitis
Rovsing sign
RLQ pain elicited by palpating left lower quadrant
Obturator sign
Passive rotation of the right leg with the patient supine and right hip and knee flexed
Psoas sign
Supine patient raises straightened right leg against resistant
Perioperative antibiotics for appendicitis
Metronidazole and ceftizoxime
intermittent and crampy abdominal pain, vomiting, obstipation, abdominal distention, hyperactive bowel sound and fever; pain usually relieved by vomiting, intestinal tube decompression or passage of intestinal contents through partial obstruction
Small bowel obstruction
distended tympanic abdomen with peristaltic rushes and high pitched tinkling sounds initially but may be absent as disorder progresses; diffuse midabdominal tenderness common; localized tenderness, abdominal guarding, rebound tenderness and rigidity concerning signs
Small bowel obstruction
abrupt onset of severe abdominal pain followed rapidly by peritoneal signs; pains begin in the epigastrium and spread rapidly throughout the abdomen with frequent early radiation of pain to the scapular areas
Perforated peptic ulcer
Diagnosis of perforated peptic ulcer
Detection of pneumoperitoneum on upright abdominal or chest x ray
high fever, acute abdominal pain that can be diffuse, localized or referred; tenderness, N/V, diarrhea or constipation
abdominal distention, rigidity, decreased bowel sounds, diffuse abdominal tenderness, rebound tenderness, guarding
Peritonitis
Antibiotics for peritonitis
3rd or 4th generation cephalosporin or quinolone
Decline in leukocyte count after 24-48 hours after antimicrobial therapy
abdominal, flank, or back pain with radiation to the back
Pulsatile painful mass palpated in the abdomen, aortic bruit
Ruptured aortic aneurysm
Risk factors for cholesterol stones
female, obesity, pregnancy, aging, drug induced, cystic fibrosis, rapid weight loss, spinal cord injury, ileal disease, DM, sickle cell anemia
biliary colic with intermittent or steady, right upper quadrant abdominal pain that radiates to the right posterior shoulder within an hour of eating any type of large meal, specifically high fat
Cholecystitis/cholelithiasis
Drugs that increase risk of cholelithiasis
Fibric acid derivatives, contraceptives, steroids, estrogen, progesterone, sandostatin, ceftriaxone
RUQ tenderness and guarding and rigidity, distended gall bladder, hypoactive bowel sounds, positive murphy sign, jaundice, dehydration
Cholecystitis
Cirrhosis
End stage consequence of progressive hepatic fibrosis affecting normal liver function; serious, irreversible disease which is the result of exposure to persistent toxins and resulting in liver failure and death
autoimmune destruction of the intrahepatic bile ducts and eventual development of cirrhosis and liver failure
Primary biliary cirrhosis
jaundice, spider angiomata, gynecomastia, ascites, splenomegaly, palmar erythema, digital clubbing, and asterixis may be presenting signs; liver may be nodular, firm, enlarged or shrunken and spleen may be enlarged; fluid wave and increased abdominal girth if ascites is present
Cirrhosis
Tx of cirrhosis
Immunizations: pneumococcal, flu, hep A and B
Eliminate NSAID and alcohol
Antiviral for Hepatitis
Prevention of GI bleeding in cirrhosis
Administer a beta blocker (propranolol), consult with gastroenterologist, monitor PT and platelet count
Constipation
<3 bowel movements per week + passage of hard or lumpy stools, sensation of straining, feeling of incomplete evacuation, use of manual maneuvers to aid defecation
Alarm symptoms constipation
sudden change in bowel habits, weight loss >10 pounds, blood in stool, anemia, family history of colon cancer or inflammatory bowel disease, constipation resistant to treatment >50 years old
Chronic constipation differential
low dietary fiber, fundamental constipation, IBS, fecal impaction, anal fissure, hemorrhoids, drug induced, bowel tumors
First line constipation meds
Bulking agents
Psylliym, methylcellulose, polycarbophil
Stool softeners
Docusate sodium, mineral oil
Osmotic laxatives
Magensium hydroxide, PEG, lactulose, sorbitol
Stimulant laxative
Senna, bisacodyl
Osmotic diarrhea
Lactase deficienc, magneisum sulfate, small bowel injury
Secretory diarrhea
Bacterial enterotoxins such as E Coli, laxative abuse, bile salt malabsorption, endocrine tumors
Treatment of C diff
Metronidazole or vancomysin
Treatment of IBD diarrhea
Sulfasalazine or mesalamine + steroid
Risk factors for diverticulitis
Consumption of red or processed meats, obesity, smoking, low fiber diet
Diverticulosis
asymptomatic or symptomatic presence of noninflamed multiple colonic diverticula: outpouching or mucosa through colon wall
may have flattened or ribbon like to hard pellet stools; may have alternating diarrhea and constipation, bouts of steady or crampy pain mainly in left lower quadrant and abdominal distention
Diverticulitis
complicated disease associated with inflammation in or more of the diverticula with possible resultant perforation leading to abscess or fistula formation
mild to moderate, colicky to steady, aching abdominal pain usually present in the left lower quadrant accompanied by fever and leukocytosis; may be loose stools or constipation and may be N/V
Treatment of diverticulitis
May have spontaneous resolution
Clear liquids, limit physical activity
Oral abx: Bactrim + metronidazole OR augmentin or Cipro + metronidazole
Short term low fiber diet
Treatment of choice for GERD
Prescription PPI
Prevents acid production at the final juncture of the histamine, gastrin and acetylcholine pathways
-Prazole
Barrett esophagus
Infrequent, pre-malignant condition associated with chronic >5 years esophageal injury resulting from reflux
Patches of normal gray-white stratified squamous cell mucosa of the esophagus change into the light pink columnar epithelium
Hepatitis A
caused mostly by contaminated food or water; risk factors include crowded conditions (prisons, nursing homes, daycares)
Transmitted by fecal oral route but can be detected in blood
Can be excreted in feces 2 weeks before symptoms
Hepatitis C
Risk factors: IV drug use, sex with IV drug user, tattooing, body piercing, alcohol use
Nonalcoholic fatty liver disease
Associated with metabolic syndrome–abdominal obesity, hyperlipidemia, and diabetes
anorexia, fatigue, myalgias, nausea, fever, headaches, arthralgias, vomiting and abdominal pain; jaundice is rare
Hepatitis
most accurate test to determine amount of inflammation and scarring in the liver
Biopsy
Chronic inflammation of the lining of the colonic mucosa and the submucosal layer; beginning in the rectum and may involve the entire colon or only part of the colon (Worse in the rectum)
4-10 bowel movements per day; small to large amountso f blood and mucous; abdominal pain, impaired nutrition
Ulcerative colitis
Smoking protective
Friability, erosions and bleeding
All layers of the intestinal tract wall are affected; can occur in segments of the GI tract (patchy)
Diarrhea with blood intermittently, steatorrhea, abdominal cramping and pain
Crohn Disease
Fistulas can occur
Smoking makes worse
abdominal pain (diffuse or localized to the right or left lower quadrants); spasms, urgency and fecal incontinence may be reported with active rectal inflammation; stools loose or watery and may have blood
Inflammatory bowel disease
1st line for IBD
Mesalamine, sulfasalazine (5-aminosalicylic acid)
Medications for IBS
Antispasmodics–dicyclomine (bentyl)
Anti-diarrheals, anti-constipation, antidepressant
Cornerstones of antiemetic therapy
5-HT3 recepto blockers: ondansetron and dolasteron
Treatment of generalized N/V
Bismuth subsalicylate, metoclopramide, prochlorperazine, promethazine
Treatment of nausea associated with chemo
Serotonin blockers (ondansetron), dopamine receptor blockers (phenothiazines), cannabinoids, benzos
Treatment of motion sickness
Antihistamine/anticholinergic
Diphenhydramine, meclizine, promethazine, scopolamine
Ranson criteria
For acute pancreatitis
if >7 there is 100% mortality
Most common cause of pancreatitis
Gallstones
ABC causes of acute pancreatitis
Alcohol, autoimmune, arteritis, biliary, congenital, drugs, ERCP, eosinophila, formation of tumors, genetic, hyperlipidemia, hypercalcemia, idiopathic infections
sudden onset of sharp, poorly localized abdominal pain that radiates to the back
Pancreatitis
patient usually reluctant to take a deep breath due to severe abdominal pain; pain worse in supine position; abdominal distention due to leakage of fluid into the retroperitoneum; rebound tenderness are late signs
Pancreatitis
Diagnostics for pancreatitis
Serum amylase and lipase
Rise 6-12 hours after onset of symptoms
Management of acute pancreatitis
Early IV hydration
Pain treated with opioid–demerol
Clear fluids when pain-free
Causes of chronic pancreatitis
Chronic alcoholism, duct obstruction from tumors, hypercalcemia, hyperlipidemia, genetics, autoimmune
abdominal pain epigastric with potential referral to upper back, anterior chest or flank; N/V may accompany the pain; pain intensifies with alcohol or fatty food; weight loss, diarrhea and steatorrhea due to fat
Pancreatitis
2 types of PUD
NSAID or H Pylori
epigastric pain (sharp, burning, aching, gnawing pain) or dyspepsia; pain usually relieved by food or antacids or have pain with eating
PUD
1st line therapy for PUD
Antisecretory therapy
Discontinue NSAID or COX-2 inhibitors
H2 blockers for PUD
Cimetifine, famotidine, nizatidine, ranitidine
PPI for PUD
Omeprazole, lansoprazole, rabeprazole, esomeprazole
Prostaglandin therapy for PUD
Misoprostol only available agent for NSAID induced gastric ulcer
H Pylori treatment
- Omeprazole + Clarithromycin, then omeprazole
- Ranitifine bismuth + Clarithromycin, then ranitidine
- Bismuth subsalicylate + Metronidazole + Tetracycline + ranitidine
- Lansoprazole, amoxicillin, and clarithromycin
1st line treatment for fever
Acetaminophen
Differentials for lymphadenopathy CHICAGO
Cancers, hypersensitivities, infection, connective tissue disease, atypical lymphoproliferative disorders, granulomatous lesions, other
fever, chills, headache, malaise, myalgia, loss of appetite
dry cough, nasal congestion with clear discharge and sore throat
Influenza
4 treatments of flu
Amantadine, rimantadine, zanamivir, oseltamivir
Most common cause of acute diarrhea
Norovirus
Most common organism for travelers diarrhea
E Coli
Abx for travelers diarrhea
Cipro or azithromycin
Treatment of C Diff
Oral metronidazole or oral vancomycin
food poisoning 1-6 hours after ingestion
Staph aureus, bacillus cereus
food poisoning 8-14 hours aftrer ingestion
Clostridium perfringens, bacillus cereus
fever, pharyngitis, lymphadenopathy, fatigue, atypical lymphocytosis, may have palatal petechiae, hepatomegaly, splenomegaly
mono
pink-red spherical rash at the site of the tick bite called erythema migrans; usually appears within 3-30 days of the tick bite; has a target-like lesion with central clearing that is painful, burning or itchy
Early localized lyme disease
Secondary annular lesions, severe malaise or fatigue, headache, fever, chills, regional or generalized lymphadenopathy, migratory arthralgias or arthritis, splenomegaly, neurologic abnormalities, AV block, pancarditis, conjunctivitis, hepatitis, sore throat, sough; occurs within several weeks
Early disseminated lyme disease
Spastic paraparesis, scleroderma like lesions, ataxic gait, mental disorders, keratisis, fatigue; occurs months after disease onset
Late persistent lyme disease
Treatment of lyme disease
Doxycycline
Second line is amoxicillin
fever, severe headache and rash (usually begins around wrist and ankles and may involve the palms and soles)
Rocky mountain spotted fever
fatigue, anorexia, weight loss, night sweats, cough, chest pain, hemoptysis, irregular mesnes, low grade fever
TB
First step for TB management
Screening with mantoux test
Major side effects of INH
Hepatitis, peripheral neuropathy
Sprain
Ligament injury
Strain
Tendon injury
Fibromyalgia
> 3 months of musculoskeletal pain present in 19 areas as well as severity of symptoms associated with fibromyalgia
Predominant cause of hyperuricemia
Undersecretion of urate by the kidneys
Treatment of acute gout flare up
NSAIDs, colchichine, steroids, ACTH
Long term treatment of gout
Allopurinol
Gout prevention diet
Low purine, low protein, alcohol restricted diet
Radicular back pain
Often have leg and thigh pain greater than back pain; may have numbness, tingling, weakness, reflex changes and root tension signs
Exacerbated by prolonged sitting, coughing, sneezing, bending
Medications for low back pain
Ice, heat, NSAIDs or acetaminophen, skeletal muscle relaxants (cyclobenzaprine)
Drop arm test
Shoulder injury
Empty can test
Rotator cuff injury
Impingement test
Shoulder injury
Hawkin test
Shoulder injury
Spurling test
Shoulder injury
shoulder pain aggravated by movement, especially overhead activity and radiating to the anterior aspect of the arm; abduction is painful and weak and tenderness may be elicited over the insertion of the greater tuberosity
Rotator cuff tear
increased bone fragility and increased susceptibility to fracture
Osteoporosis
Causes of osteoporosis
Aging and estrogen deficiency
Glucocorticoid use
Secondary causes of osteoporosis
Hyperparathyroidism, hyperthyroidism
Treatment of osteoporosis
Biphosphanates (alendronate, zoledronic acid), calcitonin, raloxifene, calcium 1000-1200mg, vitamin D 800-1000IU
Osteoclasts in the affected area are increased in number, size and activity and cause breakdown of focal areas of bone at great speed
Paget disease
Chief symptom of paget disease
Bone pain Often tender to touch and warm Pagetic bone noticebaly enlarged Bow shaped bones May have enlarged head
Diagnosis of Paget disease
Serum alkaline phosphatase or urinary n-telopeptide cross links level
Treatment of paget disease
Biphosphanates, calcitonin, pain management
Progressive degenerative joint process; degeneration of articular cartilage layer on the ends of the bones of the joints; increases thickness and sclerosis of the bone plate
Osteoarthritis
insidious, progressive pain or stiffness of one or more joints; prevalent on arising for less than one hour duration and after a prolonged activity and relieved by rest
Weight bearing causes pain and weakness
Osteoarthritis
Physical exam findings for OA
o Joint crepitus, deformities, swelling, gradual los of motion as condition progresses
o Heberden’s nodes: distal
o Bouchard’s nodes: proximal
o OA of the hip manifests with groin or buttock pain that can radiate to the knee—resultant gait is Trendelenburg gait
Tx of OA
Acetaminophen, NSAIDs, tramadol
• Autoimmune disorder characterized by symmetric inflammatory polyarthritis and varying degrees of extra-articular involvement
RA
Physical exam of RA
o Ulnar deviations, swan neck deformity, boutonniere deformity of thumb
n palpation, inflamed joint feels warm and tender and the synovial membrane feels thickened and boggy; skin may look shiny and have a ruddy color
Sjogren syndrome
Commonly seen in RA patients
characterized by dry eyes and dry mouth—due to immune mediated destruction of the salivary and lacrimal glands
Treatment of RA
DMARDs
Steroids
NSAIDs
Chronic multisystem inflammatory rheumatic disease
SLE
malaise and fatigue, anorexia and weight loss, fevers, lymphadenopathy, tachycardia, anemia, butterfly rash, discoid lupus rash, discoid lupus skin lesions
SLE
Management of SLE
Avoid sun exposure
Low dose omega 3
Steroids, statins, NSAIDs, hydroxychloroquine, immunosuppresants
Reversible vasospastic disorder that affects the blood flow to the digits
Raynauds
classic tricolor changes of first white, then blue and then red after vasospasm ends; can be triggered by cold exposure, rapid changes in ambient temperature or emotional stress; may involve single digits or multiple body parts
Raynaud’s
Management of SLE
Environmental measures–keep body warm, stress management, strict avoidance of smoking
Vasodilators (nifedipine), antiplatelets (aspirin), oral and inhaled prostaglandin inhibitors
Addison disease
Primary adrenal insufficiency
Chronic malaise, dizziness, nausea, chronic abdominal pain, muscle cramps, hyperpigmentation, decreased libido, weight loss, salt craving
Decreased axilla and pubic hair
Diagnostics of Addison disease
elevated serum ACTH and decreased cortisol; hyponatremia and hyperkalemia, screen for TB
Management of addison disease
Outpatient: oral hydrocortisone, mineralocorticoid replacement with fludrocortisone
Cushing syndrome
Overproduction of cortisol
Central obesity, moon face, buffalo hump, muscle weakness and wasting, hirsutism, red-purple abdominal skin striae of >1cm
Cushing syndrom
o Catecholamine-secreting tumor of chromaffin cells
Pheochromocytoma
Hallmark of new onset of moderate to severe hypertension with systolic pressure >170
Pheochromocytoma
Management of pheochromocytoma
Surgical removal
Leading cause of cardiovascular disease, renal failure, blindness, and nontraumatic lower limb amputation
Diabetes
Pre-diabetic lab values
o FPG: 100-125
o OR 2 hour plasma glucose 140-199
o OR A1C 5.7-6.4%
Early morning hyperglycemia controlled by
Basal insulin
Postmeal glucose spikes controlled by
Prandial insulin
Rapid acting insulin
Lispro, aspart, glulisine
Give just before, during or immediately after a meal
First drug for type 2 DM
Metformin
Postmeal BG should be
<180 1-2 hours after eating
Routine labs for DM
HbA1C every 3 months, yearly urinary microalbumin and urinalysis, BUN, Cr, ophthamology, lipid profile
After initiating lipid lowering drugs, a second panel should be obtained in
4-12 weeks
Initial test of liver fx before beginning statins
Most sensitive indicator of overall thyroid function
TSH
If TSH abnormal,
A free T4 should be obtained
Most common cause of goiter in the world
Iodine deficiency
Most common cause of hyperthyroidism
Graves disease
Drug induced hyperthyroidism
Amiodarone, interferon alfa, lithium
Management of tremors and palpitations in Graves
Propranolol or atenolol
Thiamide therapy for hyperthyroidism
Methimazole and PTU
Baseline CBC and liver function tests
Pregnancy and thiamides
PTU limited to first trimester
Management of hypothyroidism
Levothyroxine
Check TSH every 6 weeks until stable and then every 6-12 months
Take 2 hours before or 4 hours after food
Monitor BG levels
Incontinence and aging
Not considered normal at any age
loss of urine associated with activities that increase intra-abdominal pressure
Stress incontinence
involuntary loss of urine usually preceded by a strong, unexpected urge to void
Urge incontinence
Overactive bladder
involuntary loss of urine associated with incomplete emptying
Overflow incontinence
Tx of stress incontinence
Timed voiding, smoking cessation, weight loss, pelvic muscle exercises, bowel management
Alpha agonists, TCAs, estrogen
Tx of urge incontinence
Bladder training, scheduled voiding, bladder irritant minimization, urge suppression
Anticholinergic-antimuscarinics (Oxybutynin)
Tx of overflow incontinence
Timed voiding, clean intermittent catheterization
Alpha 1 blockers, 5-alpha-reductase inhibitors
Main mediator of prostate growth
DHT
Management of BPH
alpha blockers: terazosin, dozazosin
5-alpha reductase inhibitors: dustaseride and finasteride (may take 6-12 months)
Most common sign of bladder cancer
Hematuria
Hallmark clinical signs of CKD
Decreased GFR, increased serum Cr and albumin in urine
Management of ED
Phosphodiesterase type 5 inhibitors: enhance effects of NO and block degradation of cGMP; do not initiate an erection–sildenafil, vardenafi, tadalafil
increased frequency, urgency, dysuria, suprapubic pain, odorous urine, hematuria occasionally
UTI
Management of UTI
Nitrofurantoin
Cephalexin
Amoxicillin
Augmentin
Tx of chlamydia
Azithromycin 1g or doxycycline
Tx of gonorrhea
Ceftriaxone IM + azithromycin or doxycycline
Tx of syphilis
Penicillin
Tx of herpes
Acyclovir
Discoid rash
Present in SLE
Lachman test
Identifies integrity of ACL
with the knee flexed 20-30°, the tibia is displaced anteriorly relative to the femur; a soft endpoint or greater than 4 mm of displacement is positive (abnormal)
Anterior drawer test
Identify integrity of ACL
Bouchard node
RA; proximal interphalangeal joints
Heberdens nodes
RA; distal interphalangeal joints
Dawn phenomenon
abnormal early morning increase in blood sugar (between 2 and 8am)
Somogyi effect
rebound hyperglycemia after an episode of hypoglycemia when sleeping
Murphy’s sign
palpate gallbladder medial to midclavicular line while patient lying supine; tests for cholecystitis
McBurney’s sign
tests for appendicitis
Bulls eye rash
Lyme disease
TB PPD >5mm is positive for
recent contact with active TB patient, nodular or fibrotic changes in chest X ray, organ transplant
PPD >10mm positive for
recent antivirals, IV drug use, congregate settings, mycobacteriology lab personnel, comorbid conditions, children <4, infants, children and adolescents exposed to high risk categories
PPD >15mm positive for
Persons with no known risk factors for TB
Phenazopyridine
Analgesia used to treat dysuria
Normal TSH
0.4-4
When to repeat C4 count in hIV
every 3-4 months
how much carbs to give if hypoglycemic
15g
hematuria
Defined as >3RBC per high power field
Proteinuria value
> 150mg per day
30-150mg per day is early renal disease
Most accurate way to quantify protein in urine
24 hour urine collection
Bence jones protein associated with
multiple myeloma
Transient urinary incontinence related to
Delirium, infection, medications, underlying systemic illness
overflow incontinence causes
DM, injuries to sacral cord, outlet obstruction
Causes of stress incontinence
Laxity of pelvic floor, bladder outlet or sphincter weakness
Do not prescribe Bactrim for UTI if
Resistance >20% E Coli
Sudden onset fever, shaking, chills, N/V, unilateral or localized flank pain, fatigue, diarrhea
Pyelonephritis
Urinalysis positive for…. in pyelonephritis
Bacteria, proteinuria, leukocyte esterase, urinary nitrites, hematuria, pyuria, WBC casts
Diagnostic for pyelonephritis
Presence of WBC casts
Most common kidney stones
MoCalcium oxalate or calcium phosphate
Struvite stones
Found predominantly in women; associated with UTI; occur when urine is alkaline
Oxalate rich foods
beets, black tea, chocolate, lamb, nuts, rhubarb, spinach
Purine rich food
Red meat, seafood, poultry, legumes, whole grains, alcohol
sudden and rapid deteriotation of renal function, resulting in an accumulation of nitrogenous wastes
Acute renal failure
Often completely reversible
Most common causes of AKI
Intrarenal causes by nephrotoxins
Decreased blood flow to the kidneys
Phases of acute renal failure
Initiation
Maintenance/oliguric
Recovery: diuresis common; may have plyuria
Common cause of intrarenal failure
Acute tubular necrosis
Hallmark signs of renal failure
Decreased GFR
Increased serum Cr and albuminuria
Treatment of prostatitis
Fluoroquinolone
Bactrim or doxycycline
Treatment of nonbacterial prostatitis
may benefit from eyrthromycin, bactrim or fluoroquinolone
Screening for syphilis
RPR
Causes of epididymitis
STI
What will relieve pain with epididymitis
Elevaiton of testes
Tx of epididymitis
One time dose of ceftriaxone IM and doxycycline
Cipro or Bactrim if not STI
Nonpharm tx of epididymitis
Bed rest with scrotal eelvation; ice pack or warm compresses, avoidance of physical straining
