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Family Medicine Clerkship- Case files > GI/GU complaints > Flashcards

GI/GU complaints Flashcards

1
Q

What is the next diagnostic step in the case of acute gastroenteritis (acute diarrhea)?

A
  • Order stool for fecal leukocytes
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2
Q

What are the potential complications of acute gastroenteritis?

A
  • Dehydration and electrolyte abnormalities
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3
Q

Bloody diarrhea is generally caused by which organisms?

A
  • EHEC
  • Yersinia
  • Shigella
  • Entamoeba histolytica
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4
Q

What are common bacterial etiologies of traveler’s diarrhea?

A
  • E. coli (especially ETEC)
  • Salmonella
  • Shigella
  • Vibrio (non cholera)
  • Campylobacter
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5
Q

What are common viral etiologies of traveler’s diarrhea?

A
  • Rotavirus

- Norovirus

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6
Q

What are common parasitic etiologies of traveler’s diarrhea?

A
  • Giardia lamblia
  • Entamoeba histolytica
  • Cryptosporidium parvum
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7
Q

How might the timing of infection from eating contaminated mayonnaise containing food influence diagnosis?

A
  • Within 6 hours => S. aureus
  • 8-12 hours => C. perfringens
  • 12-14 hours => E. coli
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8
Q

What organisms are often seen in daycare settings of diarrhea?

A
  • Rota virus
  • Shigella
  • Giardia
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9
Q

What infectious agent is associated with abx induced diarrhea?

A
  • C. difficile colitis
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10
Q

Though most acute diarrhea does not require work up, which cases of acute diarrhea DO require work up?

A
  • Profuse diarrhea
  • Dehydration
  • Fever >100.4F
  • Bloody diarrhea
  • Severe abdominal pain
  • Duration >2 days
  • Children and elderly
  • Immunocompromised
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11
Q

What pair of symptoms are more prone to causing hospital admissions?

A
  • Vomiting and diarrhea leading to severe dehydration requiring IV hydration
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12
Q

If a patient is losing fluid from vomiting or dehydration, what physical exam sign indicates the volume status?

A
  • Mucous membranes => moist or dry
  • Skin turgor
  • Capillary refill
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13
Q

What are the primary concerns with microscopic hematuria that should be ruled out?

A
  • renal cell carcinoma

- transitional cell carcinoma

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14
Q

How is the upper urinary tract imaged?

A
  • Intravenous pyelogram OR CT
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15
Q

How is the lower urinary tract imaged?

A
  • Cytoscopy (an endoscopic procedure)
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16
Q

What are the various types of hematuria?

A
  • glomerular
  • renal
  • urologic
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17
Q

What is seen on urinalysis in glomerular hematuria?

A
  • proteinuria
  • erythrocyte casts
  • dysmorphic RBCs
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18
Q

What is renal hematuria associated with?

A
  • tubulointerstitial disorder
  • renovascular disorder
  • metabolic disorder
  • significant hematuria
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19
Q

What are the urologic causes of hematuria?

A
  • tumors
  • calculi
  • infections
  • trauma
  • BPH
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20
Q

What is seen on UA in cases of urologic hematuria?

A
  • nothing: no proteinuria, dysmorphic RBCs, or erythrocyte
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21
Q

What are risk factors for hematuria?

A
  • Smoking
  • Occupational exposure to chemicals or dyes (benzenes or aromatic amines- think hair dressers)
  • History of gross hematuria
  • > 40 years old
  • History of urologic disorder/disease
  • History of voiding symptoms
  • History of urinary tract infection
  • Analgesic abuse
  • History of pelvic irradiation
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22
Q

What abnormalities on a urinalysis should prompt evaluation for renal parenchymal disease (i.e. referral to nephrology)?

A
  • Proteinuria
  • Red cell casts
  • Renal insufficiency
  • Predominance of RBCs
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23
Q

What test will help differentiate between glomerular disease and interstitial disease?

A
  • Urinary sediment
    • Renal glomerular disease => dysmorphic red cells
    • Interstitial disease (analgesic/med use) => eosinophils in the urine
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24
Q

What are the next diagnostic steps in working up chronic kidney disease?

A
  • Serum electrolytes
  • blood urea nitrogen
  • creatinine
  • imaging of the kidneys
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25
Q

What is the next step in therapy in initial presentation of chronic kidney disease?

A
  • Stop any offending agents like NSAIDs
  • Control BP
  • Control other chronic illnesses (like DM)
  • Possible dialysis in the case of: pulmonary edema, severe hyperkalemia, or anuria.
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26
Q

Significant reduction in urine output warrants what types of diagnostic testing?

A
  • Creatinine
  • Volume status ( skin turgor, mucous membranes, specific gravity in the UA, orthostatic blood pressure, heart rate lying down and standing)
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27
Q

What conditions increase risk of kidney disease?

A
  • hypertension
  • diabetes mellitus
  • NSAID use
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28
Q

What metabolic imbalances commonly occur in chronic kidney disease?

A
  • hyper/hyponatremia
  • hyperkalemia
  • elevated uric acid levels
  • metabolic acidosis
  • hyperparathyroidism (increased Ca2+; failing kidneys do not absorb/convert enough active Vit D, which therefore causes more PTH to be secreted)
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29
Q

How is hyperkalemia treated?

A
  • sodium polystyrene sulfonate
  • insulin with glucose
  • retention enemas
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30
Q

When would a patient with chronic kidney disease also have symptoms of pulmonary edema?

A
  • When they can no longer compensate for failing kidneys
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31
Q

What are the symptoms of pulmonary edema?

A
  • shortness of breath
  • lower extremity edema
  • jugular venous distension
  • abnormal lung sounds (rales)
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32
Q

What are signs of hypoalbuminemia?

A

Nephrotic syndrome may manifest as:

  • frothy urine
  • lower extremity edema (from loss of protein)
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33
Q

Why might a patient with chronic kidney disease suffer from occasional emesis?

A
  • Emesis is due to high levels of urea and other toxins not excreted due to failing kidneys
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34
Q

Why would normocytic anemia occur in the context of chronic kidney disease?

A
  • Chronic kidney disease decreases the amount of erythropoietin formed, leading to normocytic anemia
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35
Q

What types of agents treat blood pressure and improve kidney function?

A
  • ACE-I

- ARbs (angiotensin receptor blockers)

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36
Q

What are the most common causes of chronic kidney disease?

A
  • Diabetes
  • Hypertension
  • Glomerulonephritis
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37
Q

Shrinkage of kidneys in the setting of chronic kidney disease is representative of?

A
  • Irreversible damage
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38
Q

Asymmetrical kidneys in chronic kidney disease represents?

A
  • renovascular disease
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39
Q

What drugs can affect kidney function?

A
  • Aminoglycosides
  • NSAIDs
  • Radiographic contrast
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40
Q

If ARB and ACE- I are combined in refractory hypertension, what should be monitored 3-5 days after initiation?

A
  • potassium and creatinine should be monitored
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41
Q

Patients with chronic kidney disease may have what dietary restrictions?

A
  • Reduced protein
  • Treat hyperlipidemia
  • Sodium restriction plus loop diuretics
  • Low potassium diet
  • Decrease calcium intake in severe stages of kidney disease (stages 3-5)
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42
Q

How should chronic kidney patients with anemia be treated?

A
  • Treat with erythropoietin
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43
Q

A 25 yo woman presents with foul smelling vaginal discharge. She has greenish, frothy discharge and a “strawberry cervix” noted on examination. What is the most likely organism causing this infection?

A

Trichomonas vaginalis

- motile flagellated trichomonads and many WBCs

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44
Q

What is the recommended treatment of trichomonas vaginalis?

A
  • metronidazole po for BOTH the patient and her partner

- screen for other STIs

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45
Q

What are common causes of vaginitis?

A
  • Candida albicans (thicker discharge)
  • Trichomonas vaginalis (frothy discharge and red cervix)
  • Gardnerella vaginalis (thin and fishy discharge)
46
Q

Women with recent abx use are most likely to develop what type of infection?

A
  • Candida albicans
47
Q

Women with diabetes are most likely to develop what type of vaginitis?

A
  • Yeast infection
48
Q

What risk factors are associated with trichomonas infection?

A
  • STI ( multiple sex partners)
  • pregnancy
  • menopause
49
Q

What would be visualized on wet mount if Gardnerella vaginalis was suspected?

A
  • Clue cells
50
Q

How is gardnerella vaginalis treated?

A
  • metronidazole or clindamycin
51
Q

What percentage of gonococcal infections and chlamydial infections are asymptomatic in women?

A
  • 50% of gonococcus is asymptomatic in women

- 70% of chlamydia is asymptomatic in women

52
Q

How is gonorrhea and chlamydia treated?

A
  • Gonorrhea => ceftriaxone

- Chlamydia => 1 week of doxycycline or 1 dose azithromycin

53
Q

What are the key features of pelvic inflammatory disease?

A
  • lower abdominal tenderness with both adnexal and cervical motion tenderness
  • Temperature >101F
  • Vaginal discharge
  • Elevated ESR
  • Elevated CRP
  • Cervical infection of gonorrhea or chlamydia
54
Q

What test should be done on all patients with PID?

A
  • Patients with suspected PID should have a pregnancy test administered because of the clinical similarity with ectopic pregnancy
55
Q

What are the most common causes of lower GI bleed in the elderly?

A
  • Tumors
  • Diverticulitis
  • Hemorrhoids
  • Ulcerative colitis
56
Q

What are symptoms of anemia?

A
  • weakness
  • fatigability
  • pallor of the conjunctivae or skin
  • chest pain
  • dizziness
  • tachycardia
  • hypotension
  • orthostasis
57
Q

What are major causes of mortality/morbidity in GI bleeding?

A
  • blood aspiration

- shock

58
Q

What is the test of choice to determine the source of a lower GI bleed?

A
  • Colonoscopy
59
Q

What is an alternative to colonoscopy in the determination of a lower GI bleed?

A
  • Sigmoidoscopy with air contrast barium enema xrays
60
Q

What are risk factors for hemorrhoids?

A
  • chronic constipation
  • straining for bowel movements
  • pregnancy
  • prolonged sitting
61
Q

What is the conservative treatment for hemorrhoids?

A
  • High fiber diet
  • stool softeners
  • precautions against prolonged straining
  • surgical intervention when necessary
62
Q

What is the typical presentation of diverticulitis?

A
  • left lower quadrant abdominal pain

- fever, nausea, diarrhea, and constipation

63
Q

What is the treatment of diverticulitis?

A
  • bowel rest
  • treatment with abx against bowel flora (quinolone + metronidazole)

*surgery in severe cases

64
Q

Define ulcerative colitis.

A
  • continuous inflammation of the large bowel from the rectum extending proximally
65
Q

Define Crohn’s disease.

A
  • causes areas of focal inflammation, but can occur anywhere in the gastrointestinal tract
66
Q

What are extraintestinal manifestations of IBD?

A
  • arthritis
  • sclerosing cholangitis
  • cirrhosis
  • fatty liver
  • pyoderma gangrenosum
  • erythema nodosum
67
Q

What malignancy is related to ulcerative colitis?

A
  • colon cancer
68
Q

List the types of adenomatous polyps in order of malignant potential.

A
  • Tubular adenomas (least likely)
  • Tubulovillous adenomas
  • Villous adenomas ( most likely)
69
Q

What would UA show in the case of a UTI?

A
  • bacteriuria
  • pyuria
  • nitrites
  • leukocyte esterase
70
Q

What is the most appropriate work up for suspected irritable bowel syndrome?

A
  • CBC

- stool hemoccult test (guaiac)

71
Q

What is the best initial trial for IBS/constipation?

A
  • fiber supplementation
72
Q

What is lubiprostone/amitiza?

A

Pharmacologic agent that selectively activates intestinal chloride channels and increases fluid secretion. It is approved for IBS in WOMEN with constipation, but as a side effect of nausea in many patients

73
Q

What is the gender prevalence of IBS?

A
  • Affects women 3 times more than men

- Tends to affect young women 20-30

74
Q

What cluster of illnesses also tend to coexist with IBS?

A
  • fibromyalgia
  • low back pain
  • chronic headahces
75
Q

What are the chief complaints of someone with IBS?

A
  • constipation
  • diarrhea
  • alternating constipation and diarrhea
  • often left lower quadrant abdominal pain which tends to improve with defecation
  • in severe cases: nighttime awakenings
76
Q

What other GI symptoms might a person with IBS complain of?

A
  • up to 50% of patients with IBS also have symptoms of dyspepsia, nausea, GERD
77
Q

What are GI alarm features?

A
  • fever
  • anemia
  • involuntary weight loss greater than 10lbs
  • hematochezia
  • melena
  • refractory or bloody diarrhea
  • family history of colon cancer
  • family history of IBD
78
Q

What workup should be done in patients with IBS symptoms who are over 50?

A
  • CBC
  • hemoccult test
  • AND colonoscopy
79
Q

What agents are used for IBS related abdominal pain?

A
  • dicyclomine and hyoscyamine (antispasmodics on prn basis)
  • low dose TCA when pain is frequent and severe
  • If comorbid depression/anxiety, use SSRI
80
Q

What agents are used for IBS related constipation?

A
  • increasing fiber intake
81
Q

What agents are used for IBS related diarrhea?

A
  • loperamide/imodium
82
Q

How is a diagnosis of Hep A infection confirmed?

A
  • Anti-hep A immunoglobulin (Ig) M
  • Remember that IgM indicates acute infection, whereas IgG indicates past infection
  • Elevated conjugated bilirubin and elevated hepatic transaminases also help
83
Q

What is the treatment for Hep A infection?

A
  • supportive care and symptomatic treatment for the patient
  • report infection to local health department
  • consider Ig prophylaxis to household/sexual contacts
84
Q

What is the most common cause of prehepatic jaundice?

A
  • Hemolysis of RBCs => overwhelms the liver’s ability to conjugate and clear the bilirubin through its normal pathways
  • Produces primarily unconjugated bilirubin
85
Q

What are common causes of hepatic jaundice?

A
  • Viruses
  • Alcohol induced
  • Conjugated or unconjugated
86
Q

What are common causes of posthepatic jaundice?

A
  • Usually caused by obstruction to the flow of bile through the bile ducts
  • Can be caused by bile duct stones, strictures, or tumors that narrow or block the ducts
  • Conjugated hyperbilirubinemia
87
Q

What is a common symptom of jaundice that may actually precede the onset of yellow color?

A
  • pruritis
88
Q

What OTC pain killer when used in large amounts can cause hepatotoxicity?

A
  • Acetominophen
89
Q

Right upper quadrant pain can indicate what organ issues?

A
  • Liver (hepatitis)

- Gallbladder (gallstones)

90
Q

Splenomegaly in the context of jaundice is indicative of?

A
  • portal hypertension from cirrhosis
  • malignancy
  • splenic sequestration of damaged RBCs
91
Q

When measuring bilirubin, direct bilirubin is equivalent to?

A

Direct bilirubin = conjugated bilirubin

* conjugated is also excreted in the urine

92
Q

What is Gilbert’s syndrome?

A
  • Often an incidental finding of increased unconjugated bilirubin that is caused by a congenital reduction of conjugation of bilirubin in the liver
  • It is of NO health consequence and affects approximately 5% of the population
93
Q

What percentage of Hep B infections become symptomatic?

A
  • 50%

- only 1% of these result in hepatic failure and death

94
Q

What infected age group is most likely to develop chronic hep B?

A
  • Children, particularly infants (90%) and children
95
Q

What antibody is seen in resolved Hep B infection as well as vaccination?

A
  • Antibody to the surface antigen (anti-HBs) is seen in resolved infection and is the serologic marker produced after hepatitis B vaccination
96
Q

What is the most common cause of chronic liver disease in the U.S.?

A
  • Hep C
97
Q

What percentage of infected individuals will develop chronic Hep C?

A
  • 60-85%
98
Q

What is Hep D?

A
  • Hep D is a rare cause of viral hepatitis that uses the viral envelop of Hep B to infect its host and therefore requires coinfection of Hep B AND D
  • It is endemic in the Mediterranean, Middle East, and S. America
  • Can be prevented with a Hep B vaccine
99
Q

What type of hepatitis is most dangerous to pregnant women?

A

Hep E is a fecal-orally transmitted viral hepatitis that has a very high mortality rate in 2nd and 3rd trimester pregnant women

100
Q

What is the evaluation of a bleeding peptic ulcer?

A
  • CBC => eval for blood transfusion depending on blood loss
  • Stop NSAIDs
  • Upper GI endoscopy + test for H. pylori
  • Eval for colonoscopy
101
Q

What is the treatment for peptic ulcer secondary to H.pylori?

A
  • PPI and ABX
102
Q

What are alarm symptoms for which early upper GI endoscopy is recommended?

A
  • weight loss
  • progressive dysphagia
  • recurrent vomiting
  • GI bleeding
  • Family history of cancer
103
Q

How can H. pylori be tested without endoscopy?

A
  • Urea breath test

- Stool antigen test

104
Q

What is peptic ulcer disease?

A
  • PUD is a term that describes both duodenal and gastric ulcers
  • Duodenal ulcers are more prevalent overall, whereas gastric ulcers are more common in NSAID users
105
Q

What are risk factors of PUD?

A
  • H. pylori infection
  • Use of an NSAID
  • Smoking
  • Family/personal history of PUD
  • Black and Latino heritage
106
Q

What are symptoms of PUD?

A
  • epigastric abdominal pain that is improved with the ingestion of food
  • Pain that develops a few hours after eating
  • Nocturnal symptoms
107
Q

Epigastric pain that radiates to the back and is associated with nausea and vomiting are symptoms of?

A
  • Pancreatitis
108
Q

How can an active H. pylori infection be confirmed?

A
  • urea breath test
109
Q

What is the gold standard for H. pylori testing?

A
  • Endoscopy with biopsy
110
Q

What are possible complications of PUD?

A
  • Hemorrhage
  • perforation
  • gastric outlet obstruction
111
Q

When should a patient with PUD symptoms be referred for upper GI endoscopy?

A
  • > 55yo or with alarm symptoms
112
Q

What is triple therapy for H. pylori treatment?

A
  • Bismuth subsalicylate + metronidazole + tetracycline
  • Ranitidine bismuth citrate + tetracycline + clarithromycin/metronidzazole
    or
  • Omeprazole + clarithromycin + metronidazole/amoxicillin

Family Medicine Clerkship- Case files (13 decks)

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