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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
Q

Usually asymptomatic. Tissue changes cause intestinal metaplasia. Complication of unmanaged GERD.
Tx depends on severity, managed by GI

A

Barrett’s Esophagus

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26
Q

Top two diagnostics for GERD

A

Endoscopy - not done for atypical or less severe symptoms

Esophageal manometry - ordered by GI

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27
Q

Dietary and lifestyle Management of GERD

A

smoking cessation, weight loss, dietary - avoid chocolate, caffeine, alcohol, spicy foods and mint. Elevate head of bed. Stay upright for 3 hrs post meals.

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28
Q

Meds for GERD

A

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.

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29
Q

disease that results from mucosal defect in gastric lining of duodenum

A

Peptic Ulcer Disease

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30
Q

Causes of Peptic Ulcer Disease

A

Helicobacter pylori, NSAIDs, Idiopathic, Zollinger-Ellison syndrome

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31
Q

causes neuro endocrine gastric tumor

A

Zollinger-Ellison syndrome

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32
Q

assess for use and educate regarding impact on gastric lining.
Includes Cox II inhibitors

A

NSAIDs (PUD)

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33
Q

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

A

Helicobacter pylori

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34
Q

Peptic Ulcer Disease Risk Factors

A

Smoking, stress
Frequent NSAIDs, aspirin or corticosteroids
Elderly - chronic NSAIDs for musculoskeletal complaints and antiplatelets

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35
Q

Epigastric pain, nausea, burning, eating, drinking or antacids improve pain,

A

Peptic Ulcer Disease

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36
Q

Warning physical exam sx for peptic ulcer disease

A

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

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37
Q

gold standard for diagnosis, H.Pylori testing with biopsy of small intestine

A

Colonoscopy

38
Q

Eradication of H. Pylori recommended in all PUD pts.

A

Daily PPIs, 7-10 days of amoxicillin and clarithromycin (recently metronidazole and flagyl due to resistance). Probiotics can be beneficial.

39
Q

Questions to ask Pt about abdominal pain

A 
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
Q

Abdomen - Inspect, auscultate and palpate

A

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
Q

important things to remember about abdominal pain

A

tachycardia and hypotension can elude an emergency. Fever can imply acute infection.

42
Q

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

A

bowel obstruction

43
Q

Epigastric or L upper quad pain
Anorexia, n&v
Worsening of pain with eating or drinking

A

Pancreatitis

44
Q

GI diagnosotic labs

A

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
Q

What to assess on Abdominal x-ray if obstruction suspected?

A

bowel gas pattern

46
Q

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

A

Appendicitis

47
Q

Types of appendicitis?

A

Simple: appendix is visible and intact
Gangrenous: necrosis of appendiceal wall
Perforated: disruption of appendix

48
Q

appendicitis Sequence of symptoms:

A
  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
Q

PE for appendicitis

A 
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
Q

Diagnostics for appendicitis

A 
CBC- elevated WBCs
Beta hCG for females of childbearing age
Amylase and lipase
r/o sickle cell disease
CRP
UA
Ultrasound
CT
51
Q

management of appendicitis

A

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
Q

complications r/t appendicitis

A

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
Q

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

A

Rome IV criteria for abdominal migraine

- must have all of the following at least twice for at least 6 months

54
Q

How to dx abdominal migraine?

A

ALL of the Rome IV criteria at least twice and for at least 6 mos

55
Q

How to tx abdominal migraine?

A

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
Q

painful linear cracks or tears in lining of the anal canal.

A

Anal & anorectal fissure

57
Q

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

A

Anal & anorectal fissure

58
Q

How would acute vs. chronic Anal & anorectal fissure appear?

A

Acute: laceration
Chronic: indurated, fibrotic appearance with tender skin tag

59
Q

How to tx anal/ anorectal fissure?

A

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
Q

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.

A

Anal & anorectal abscess

61
Q

anal and perianal pain and swelling that increases with movement, sitting, or BMs. Possibly malaise and fever

PE: redness, heat, swelling, and tenderness

A

Anal & anorectal abscess

62
Q

How to tx Anal & anorectal abscess?

meds?

A

incision and drainage. Cipro and/or metronidazole only if complicated (cellulitis, infection, immunosuppression). Fiber, stool softeners, sitz baths.

63
Q

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

A

Cholelithiasis

64
Q

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

A

Cholelithiasis

65
Q

inflammation of the gallbladder without stones → critically ill and require hospitalization

Patho poorly understood. Common causes: hypokinetic biliary dyskinesia and decreased gallbladder emptying

A

Cholecystitis → acute or chronic acalculous cholecystitis

66
Q

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.

A

Cholecystitis → acute or chronic acalculous cholecystitis

67
Q

murphys sign

A

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
Q

Diagnostics for Cholecystitis?

A

Labs:CBC with diff, LFTs, serum pancreatic enzymes, BUN/creat. Blood cx if sepsis suspected. hCG
US- gallbladder thickening and “sonographic Murphy sign”

69
Q

Tx for Cholecystitis?

A

prophylactic cholecystectomy for some. Admit to hospital for IV fluids, NGT

70
Q

Definition of colic

A

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
Q

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

A

constipation

72
Q

Tx for constipation

A

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
Q

Dx for constipation?

A

if abd discomfort, n/v: abdominal x-ray or abdominal CT and CBC

74
Q

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

A

Cow’s milk/protein intolerance/allergy

75
Q

more than 3 unformed stools/day

acute typically resolves w/o tx

A

non-infectious diarrhea

76
Q

malabsorptive disorders; results from ingested solute-rich molecules (sugar-free products containing xylitol, sorbitol, or mannitol→ poorly absorbed)

A

osmotic diarrhea

77
Q

most common. Absorptive function of gut is compromised resulting in watery stools

A

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
Q

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

A

c.diff

79
Q

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

A

dysphagia

80
Q

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)

A

Hemorrhoids

81
Q

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

A

External hemorrhoids

82
Q

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

A

Internal hemorrhoids:

83
Q

red flag sx for pts with hemorrhoids

A

increased age, family or personal history of colorectal cancer, persistent anorectal bleeding despite tx, weight loss, IDA

84
Q

PE for hemorrhoids?

A

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
Q

Dx for hemorrhoids

A 
DRE
Anoscopy
CBC with diff
Fecal occult blood 
Endoscopy
86
Q

How to tx/ manage hemorrhoids?

A

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
Q

how to tx pt with 1st-3rd degree hemorrhoids that remain symptomatic:

A

refer for in-office procedure

Rubber band ligation

88
Q

what hemorrhoid pts to refer?

A

Refer for operative management for those that fail non-operative management

89
Q

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)

A

Intussusception

90
Q

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)

A

Intussusception

91
Q

How to tx Intussusception?

A

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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