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FNPII Test 3 > GI > Flashcards

GI Flashcards

1
Q

Polymicrobial infections of upper genital tract, primarlily in young women but may occur in any female who is sexually active.
Due to previous exposure to STIs, commonly in those who have had asymptomatic chlamydia or gonorrhea and have gone untreated.

A

Pelvic Inflammatory Disease

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2
Q

Women ages 15-44 who present with lower abdominal or pelvic pain should have a speculum exam.
Presence of cervical motion tenderness, uterine tenderness or adnexal tenderness, consider ___

A

Pelvic Inflammatory Disease

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3
Q

Tx of Pelvic Inflammatory Disease

A

One time IM injections of ceftriaxone and doxycycline
Follow up in 3-5 days is very important to determine response to tx.
Educate to alert any sexual partners within last 60 days to be screened for STI
Complications - infertility

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4
Q

Represents pain syndrome of the abdomen, poorly related to gut function. Usually associated with loss of daily activities and present for >6 months.
Pain described as constant, not associated with food or stooling
May include gynecological or urological symptoms
Low back pain
Tx: empathy and reassurance
Narcotics are NOT beneficial but can worsen by slowing GI process.

A

Functional Abdominal Pain

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5
Q

fecal-oral route, usually from unpasteurized milk, undercooked eggs and meat. Pet turtles increase risk.
Self limiting in 2-7 days with oral fluid replacement
Complications include meningitis, pneumonia or infantile bacteremia
For persistent symptoms - ceftriaxone or ciprofloxacin

A

Salmonella

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6
Q

fecal-oral route, from contaminated water, egg, potato or tuna salad, raw veggies from contaminated fields. Day care centers
Complications - hemolytic uremic syndrome and bowel perforation
Usually self limiting in 2-5 days with oral fluids, if not - azithromycin or cipro.

A

Shigella

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7
Q

Raw or undercooked poultry
Complications - meningitis, cholecystitis, spontaneous abortion
Azithromycin or cipro if needed.

A

Campylobacter

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8
Q

Found normally in intestines of healthy people, transmitted by contaminated food or water,
Complications - bloody diarrhea, severe abdominal pain, dehydration, hemolytic uremic syndrome (increased risk with abx, if not resolving, hospitalize, do not just start abx)
Usually self limiting in 1-10 days

A

E. Coli.

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9
Q

Giardia, Amebic enteritis, Cryptosporidium (stool sample can identify organism, particularly with international travel)

A

Parasitic

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10
Q

Antibiotic induced, highly contagious, diarrhea with significant increase in incidence and severity over the last 10 years.
Modifiable risk factor - abx use only when necessary
Most at risk - elderly, hospitalized, inflammatory bowel disease, chronic PPIs
Tx - oral vancomycin

A

Clostridium Difficile

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11
Q

Acute watery diarrhea suspect…

A

cholera

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12
Q

How to manage infectious diarrhea

A

Early oral fluid replacement - increases intestinal permeability, reduces risk of infection along with hydration
Antidiarrheals - do not use if dx with C. Diff.
Probiotics
Prevention - hand washing, hygiene, safe food preparation, clean water

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13
Q

Diarrheal illness that occurs 3 or more times a day with > 200 gm of stool with rapid onset lasting less than 2 weeks. Rotavirus, Norovirus, Camoylobacter

A

Gastroenteritis

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14
Q

most common cause of severe diarrhea in infants and kids. Usually last 3-8 days. Can cause severe dehydration and be reoccurring.

A

Rotavirus

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15
Q

most common in humans. Transmitted via fecally contaminated food or water, person to person and aerosolization.

A

Norovirus

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16
Q

gram negative bacteria, spiral and microphyilic. Infects jejunum, ileum and colon. GI perforation is a rare complication of ileal infection. 2-7 days

A

Campylobacter

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17
Q

Diagnostics for gastroenteritis

A

Stool studies - diagnose which organism is the cause
UA - helpful in elderly
Imaging
Labs - BMP - liver and kidney function

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18
Q

How to manage gastroenteritis

A

Usually only lasts a few days and resolves on its own, does not require abx. If lasting longer than 48 hours, consider other organisms
*Monitor for warning signs, hematemesis or bloody diarrhea, likely not viral or bacterial and need to go to ER or gastro.

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19
Q

Cornerstone treatment for gastroenteritis

A

Peds - 100 ml/kg for first 4 hours then reevaluate, if still thirsty and not vomiting continue.
Adults - start with sips and chips, advance to half strength, clear fluids like jell-o, broth and popsicles.
After every liquid BM, additional fluids offered for all ages
Recommend solids with BRAT (bananas, rice, apples and toast) diet

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20
Q

Pharmacological recommendations for gastroenteritis

A

Antidiarrheals once infection is excluded or abx is no longer needed.
Antisecretory like Bismuth and Pepto - increase intestinal sodium and water reabsorption and assists with blocking neurotoxins.

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21
Q

GERD risk factors

A

Physical - Obesity, pregnancy, hiatal hernia, delayed gastric emptying, lower esophageal sphincter dysfunction.

Behavioral - smoking, chewing tobacco, alcohol, large meals before bedtime, dietary indiscretion, medications

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22
Q

Sour or bitter taste, particularly after large or late meals, burning in stomach or mid sternum, gas, burping, excessive salivation, regurgitation, chest pain

A

typical GERD symptoms

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23
Q

persistent cough, chronic sore throat, hoarseness, asthma exacerbation, excessive throat clearing, halitosis, dental erosions, gum disease, ear and nose discomfort.

A

atypical GERD symptoms

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24
Q

GERD Physical Exam Findings

Warning signs

A

dysphagia, odynophagia (painful swallowing), food bolus, melena, hematemesis, hoarseness, weight loss - refer to Gastro

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25
Usually asymptomatic. Tissue changes cause intestinal metaplasia. Complication of unmanaged GERD. Tx depends on severity, managed by GI
Barrett’s Esophagus
26
Top two diagnostics for GERD
Endoscopy - not done for atypical or less severe symptoms | Esophageal manometry - ordered by GI
27
Dietary and lifestyle Management of GERD
smoking cessation, weight loss, dietary - avoid chocolate, caffeine, alcohol, spicy foods and mint. Elevate head of bed. Stay upright for 3 hrs post meals.
28
Meds for GERD
Antacids and H2 receptor antagonists - used for maintenance only for those without erosive diagnosis PPI - taken 30-60 minutes prior to each meal for 6-8 weeks. May continue 1-2 x/d if needed. Safe in pregnancy. Can cause osteoporosis and C.Difficile with long term use. Refer for refractory GERD or if symptoms are uncontrolled.
29
disease that results from mucosal defect in gastric lining of duodenum
Peptic Ulcer Disease
30
Causes of Peptic Ulcer Disease
Helicobacter pylori, NSAIDs, Idiopathic, Zollinger-Ellison syndrome
31
causes neuro endocrine gastric tumor
Zollinger-Ellison syndrome
32
assess for use and educate regarding impact on gastric lining. Includes Cox II inhibitors
NSAIDs (PUD)
33
present in 95% of duodenal ulcers and 70% of gastric ulcers Transmitted via fecal, oral route in childhood, lasts decades Risk factor for gastric adenocarcinoma
Helicobacter pylori
34
Peptic Ulcer Disease Risk Factors
Smoking, stress Frequent NSAIDs, aspirin or corticosteroids Elderly - chronic NSAIDs for musculoskeletal complaints and antiplatelets
35
Epigastric pain, nausea, burning, eating, drinking or antacids improve pain,
Peptic Ulcer Disease
36
Warning physical exam sx for peptic ulcer disease
Melena, coffee-ground emesis, hematemesis, unintentional weight loss, anorexia Duodenal - Most common in ages 20-50 years old Older pt may not present until perforation, fewer complaints of pain before event
37
gold standard for diagnosis, H.Pylori testing with biopsy of small intestine
Colonoscopy
38
Eradication of H. Pylori recommended in all PUD pts.
Daily PPIs, 7-10 days of amoxicillin and clarithromycin (recently metronidazole and flagyl due to resistance). Probiotics can be beneficial.
39
Questions to ask Pt about abdominal pain
``` Use OLDCARTS Does appetite affect complaint Typical bowel pattern/changes Associated symptoms - early satiety, n&v Menstrual history - possible pregnancy, check for urine pregnancy in any pt who has not gone through menstruation. Previous abdominal surgery ```
40
Abdomen - Inspect, auscultate and palpate
Inspect for distension and previous surgical scars, document Auscultate for abnormal bowel sounds or bruits Palpate for pain, document whether deep or minimal elicits, rebound or guarding, or peritoneal signs Elderly - pain threshold may be higher
41
important things to remember about abdominal pain
tachycardia and hypotension can elude an emergency. Fever can imply acute infection.
42
usually due to adhesions in abdominal wall from surgery most often small intestine presents with abdominal distension and vomiting May or may not be passing flatus or having BMs Tympany with percussion over small bowel
bowel obstruction
43
Epigastric or L upper quad pain Anorexia, n&v Worsening of pain with eating or drinking
Pancreatitis
44
GI diagnosotic labs
CBC= WBC, hemoglobin and hematocrit CMP = Electrolytes, LFTs, consider amylase and lipase if worried about gallstone pancreatitis or pancreatitis UA= Information about infection and lead to confirmation of diagnosis STI=Consider if complaining of pelvic pain or sexual history warrants testing
45
What to assess on Abdominal x-ray if obstruction suspected?
bowel gas pattern
46
Inflammatory disease of the wall of the appendix, may result in perforation with subsequent peritonitis Patho: blockage of appendiceal lumen→ distension of appendix due to accumulated intramural fluid with secondary bacterial infection
Appendicitis
47
Types of appendicitis?
Simple: appendix is visible and intact Gangrenous: necrosis of appendiceal wall Perforated: disruption of appendix
48
appendicitis Sequence of symptoms:
1. Pain that starts in epigastrium or periumbilical, migration to RLQ, abdominal rigidity Pain may be diffuse or occur in other parts of the abdomen Duration of pain tends to be shorter Anorexia and nausea subacute/nonspecific sxs; crampy abd discomfort that comes and goes, malaise, change in bowel habits Constipation, diarrhea (rare) with low grade fever following onset of pain
49
PE for appendicitis
``` Pelvic exam for females Fever Abdominal pain elicited by cough Localized tenderness (McBurney point) Rovsing sign- RLQ pain with palpation Peritoneal irritation- guarding, rebound tenderness, obturator and psoas signs Markle sign (heel jar) ```
50
Diagnostics for appendicitis
``` CBC- elevated WBCs Beta hCG for females of childbearing age Amylase and lipase r/o sickle cell disease CRP UA Ultrasound CT ```
51
management of appendicitis
Immediately refer/transfer to ER for suspected appendicitis Uncomplicated appendicitis: antibiotic therapy– however can recur Perioperative systemic atbx to prevent wound infection Perforated appendix: anaerobic and aerobic atbx coverage Surgery: appendectomy w/in 24hrs sx onset
52
complications r/t appendicitis
Gangrene, perforation with peritonitis, abscess formation Pylephlebitis: septic thrombophlebitis of portal venous system Suspect if pt has shaking chills Septicemia, urinary retention, infection, small bowel obstruction, mesenteric thrombophlebitis Surgical complications
53
Paroxysmal episodes of intense acute periumbilical, midline, or diffuse abdominal pain lasting 1 hour or more Episodes not separated by weeks or months Intervening periods of usual health lasting weeks to months Stereotypical pattern and symptoms in individual patient Pain a/w 2 or more: n,v, anorexia, HA, photophobia, or pallor Symptoms unexplained after clinical evaluation
Rome IV criteria for abdominal migraine | - must have all of the following at least twice for at least 6 months
54
How to dx abdominal migraine?
ALL of the Rome IV criteria at least twice and for at least 6 mos
55
How to tx abdominal migraine?
avoid triggers - caffeine, nitrates, and amine-containing foods, excessive emotional stress, travel, altered sleep, flickering lights. Sleep and antiemetics during attack. Responds to migraine prophylactic therapy.
56
painful linear cracks or tears in lining of the anal canal.
Anal & anorectal fissure
57
trauma d/t passage of large, hard stool or frequent diarrhea. Usually occur in the posterior midline; if found elsewhere suspect other causes (STI, TB, HIV, UC) High resting sphincter tone and relative ischemia CM: severe, sharp rectal pain during and after BMs. Small amounts of bright red blood on toilet paper. Hx of tearing sensation
Anal & anorectal fissure
58
How would acute vs. chronic Anal & anorectal fissure appear?
Acute: laceration Chronic: indurated, fibrotic appearance with tender skin tag
59
How to tx anal/ anorectal fissure?
most resolve w/o tx. Increased fiber, stool softeners, and sitz-bath are first-line Anti-inflammatory suppositories or foam; topical anesthetic (lidocaine 2%) before BMs
60
infection that occurs from obstruction of the duct of an anal gland. May spread to adjacent pelvic tissue or perianal skin Patho: bacterial infection of the anal crypt glands as a result of obstruction and stasis of gland from trauma, hard stools, foreign body, or diarrhea. If abscess is chronic it can result in a fistula.
Anal & anorectal abscess
61
anal and perianal pain and swelling that increases with movement, sitting, or BMs. Possibly malaise and fever PE: redness, heat, swelling, and tenderness
Anal & anorectal abscess
62
How to tx Anal & anorectal abscess? meds?
incision and drainage. Cipro and/or metronidazole only if complicated (cellulitis, infection, immunosuppression). Fiber, stool softeners, sitz baths.
63
Gallstones (cholesterol, pigmented, or mixed) obstruct the cystic or common bile duct resulting in pain, nausea, and vomiting as result of smooth muscle spasms. Bile (aids in digesting fat) is prevented from entering the duodenum, allowing fat to pass into the intestine and cause diarrhea and excess fluid loss. The prevention of bile secretion into the small intestine causes jaundice. This process causes gallbladder inflammation
Cholelithiasis
64
most asymptomatic. RUQ abdominal pain that radiates to the right posterior shoulder 1hr after eating a meal; nausea and vomiting. Symptoms last 1-6 hrs Charcot triad: RUQ pain, fever, and jaundice → stone is lodged in common bile duct
Cholelithiasis
65
inflammation of the gallbladder without stones → critically ill and require hospitalization Patho poorly understood. Common causes: hypokinetic biliary dyskinesia and decreased gallbladder emptying
Cholecystitis → acute or chronic acalculous cholecystitis
66
CM: fever, nausea, vomiting, loss of appetite, tachycardia, RUQ tenderness, guarding, rigidity. Murphy sign: inability to take a deep breath d/t pain with palpation under the right costal margin.
Cholecystitis → acute or chronic acalculous cholecystitis
67
murphys sign
Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive.
68
Diagnostics for Cholecystitis?
Labs:CBC with diff, LFTs, serum pancreatic enzymes, BUN/creat. Blood cx if sepsis suspected. hCG US- gallbladder thickening and “sonographic Murphy sign”
69
Tx for Cholecystitis?
prophylactic cholecystectomy for some. Admit to hospital for IV fluids, NGT
70
Definition of colic
crying for no apparent reason for 3 hours or more per day and occurs 3 days or more per week in an otherwise healthy infant younger than 3 mos
71
Rome IV criteria (2 or more of the following present for at least 3 mos with onset 6mos before diagnosis): Fewer than 3 BMs/week Passage of hard or lumpy stools (Bristol stool type 1 or 2) Straining with more than 25% of defecations Feeling of incomplete evacuation or anorectal obstruction more than 25% of the time Soft, easy to pass stools are not present without the sue of medication Insufficient criteria for IBS
constipation
72
Tx for constipation
Stool diary Fiber: 25-30mg/day. Increase slowly- may cause gas and bloating. Prunes useful Bowel training: toilet 30 mins after each meal. Set feet on stool while sitting on toilet. Stool softeners (docusate sodium) or emollients (mineral oil) Probiotics osmotic laxative (polyethylene glycol, lactulose, sorbitol, mag hydroxide) Stimulant laxative (senna, bisacodyl)- ok for long term use Enemas Secretagogues- avoid if pregnant
73
Dx for constipation?
if abd discomfort, n/v: abdominal x-ray or abdominal CT and CBC
74
lactase enzyme activity (usually disappears after childhood) Diag: elimination diet. Hydrogen breath tests Can try to reintroduce lactose-containing foods slowly to build tolerance. Otherwise need calcium supplementation
Cow's milk/protein intolerance/allergy
75
more than 3 unformed stools/day | acute typically resolves w/o tx
non-infectious diarrhea
76
malabsorptive disorders; results from ingested solute-rich molecules (sugar-free products containing xylitol, sorbitol, or mannitol→ poorly absorbed)
osmotic diarrhea
77
most common. Absorptive function of gut is compromised resulting in watery stools
secretory diarrhea ``` Chemical causes: bacteria, viruses, parasites, drugs Mechanical causes: surgery, radiation Functional causes: CF; IBS-D Medications: laxatives, ABX, NSAIDs CM: nocturnal diarrhea ```
78
Consider _______if temp above 38.8C (102F), bloody diarrhea, abdominal pain, more than 6 unformed stool in 24-hr period, profuse watery diarrhea, and dehydration if patients are frail, older, or immunocompromised
c.diff
79
difficulty swallowing CM: progressive dysfunction; drooling or coughing persistent, discomfort when swallowing, sense food is getting stuck, halitosis, chest pain Diag: lateral neck films, barium swallow, manometry, or MRI DDx: obstructive lesions Tx: multidisciplinary approach
dysphagia
80
Non-pathologic venous cusions in submucosal layer of anal canal; suspended by connective tissue fo internal anal sphincter Normal part of anatomy: help maintain anal closure and continence Classified based on location: external (below dentate line), internal (above dentate line)
Hemorrhoids
81
tissue highly innervated by somatic nerves– very sensitive Asymptomatic unless thrombosis develops Acutely painful perineal lump Anal irritation, pruritis Edema Severe pain if thrombosed, gradually subsides after a few days
External hemorrhoids
82
no somatic sensory nerves, usually painless Classified by degree of prolapse 1st degree: bright red, painless bleeding, may bulge, do no prolapse, reduce spontaneously 2nd degree: prolapse during defecation, reduce spontaneously; bleeding, perineal itching 3rd degree: prolapse with defecation, require manual reduction; pain secondary to local ischemia and mucoid drainage. 4th degree: permanently prolapsed, not reducible Incarcerated 4th degree requires urgent surgical intervention
Internal hemorrhoids:
83
red flag sx for pts with hemorrhoids
increased age, family or personal history of colorectal cancer, persistent anorectal bleeding despite tx, weight loss, IDA
84
PE for hemorrhoids?
Inspect perineum and perianal area Prolapse may protrude with Valsalva External: visualized around anal orfice when patient bears down DRE- palpate abnormal lesions in anal canal Internal hemorrhoid not palpable unless thrombosed Anoscopy- direct visualization Severe rectal pain may suggest gangrenous or thrombosed hemorrhoid
85
Dx for hemorrhoids
``` DRE Anoscopy CBC with diff Fecal occult blood Endoscopy ```
86
How to tx/ manage hemorrhoids?
Tx based on degree of patient’s symptoms Non Pharm High-fiber diet (20-30g/day), increased fluid intake Evacuate thrombosis (if identified within 3 days of onset) Sitz bath Topical anesthetics, mild analgesics Pharm Stool softeners Topical analgesics, hydrocortisone creams, suppositories/foams Phlebotonics: 1st and 2nd degree hemorrhoids: decrease vascular endothelial inflammation, normalize capillary permeability
87
how to tx pt with 1st-3rd degree hemorrhoids that remain symptomatic:
refer for in-office procedure | Rubber band ligation
88
what hemorrhoid pts to refer?
Refer for operative management for those that fail non-operative management
89
telescoping of the bowels; typically seen before age 2 | CM: triad: intermittent colicky/crampy pain, vomiting, and bloody mucous stools (triad only seen in 25% pts)
Intussusception
90
PE: sausage-like mass in RUQ with emptiness in RLW (Dance sign); abdomen distended and tender to palpation; bloody or guiac-positive stools Diag: US (abd x-ray may appear normal)
Intussusception
91
How to tx Intussusception?
Emergency referral for surgical consult or radiological reduction Complications: necrosis of bowel requiring bowel resection, perforation with sepsis; reoccurance

FNPII Test 3 (7 decks)

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