Mod 1: Butarro CH. 109-136 Flashcards
An adult patient reports intermittent, crampy abdominal pain with vomiting. The provider notes marked abdominal distention and hyperactive bowel sounds. What will the provider do initially?
a. Admit the patient to the hospital for consultation with a surgeon
b. Obtain upright and supine radiologic views of the abdomen
c. Prescribe an antiemetic and recommend a clear liquid diet for 24 hours
d. Schedule the patient for a barium swallow and enema
b. Obtain upright and supine radiologic views of the abdomen
Patient has S&S of SBO must confirm because SBO can be life threatening and requires hospitalization
Confirmed by upright and supine views of abdomen.
SBO caused by distention r/t obstruction or Ileus can cause a decrease in absorption of fluid and electrolyte imbalances.
relief is by NG decompression and may require surgery dependent on severity
Because small bowel obstruction can have potentially serious or life-threatening consequences, waiting 24 hours is not recommended.
A patient is in clinic for evaluation of sudden onset of abdominal pain. The provider palpates a pulsatile, painful mass between the xiphoid process and the umbilicus. What is the initial action?
a. Order a CBC, type and crossmatch, electrolytes, and renal function tests.
b. Perform an ultrasound examination to evaluate the cause.
c. Schedule the patient for an aortic angiogram.
d. Transfer the patient to the emergency department for a surgical consult.
d. Transfer the patient to the emergency department for a surgical consult.
This patient has symptoms and physical findings consistent with a ruptured aortic aneurysm and should have an immediate surgical consult. Ordering other tests is not necessary by the primary provide
AAA may go undiagnosed until symptomatic and at that point it is emergent. size typically is greater that 5.5cm
masses can be caught on exam but must determine size with CT
- Which symptoms noted in a patient reporting abdominal pain are suggestive of appendicitis? (Select all that apply.)
a. Abdominal rigidity along with pain
b. Pain accompanied by low-grade fever
c. Pain occurring prior to nausea and vomiting
d. Pain that begins in the left lower quadrant
e. Prolonged duration of right lower quadrant pain
a. Abdominal rigidity along with pain
b. Pain accompanied by low-grade fever
c. Pain occurring prior to nausea and vomiting
Patients with appendicitis typically have pain that begins in the epigastric or periumbilical area and migrates to the left lower quadrant. Abdominal rigidity is common, as is low-grade fever.
McBurneys point is localized tendernesss in RLQ b/w umbilicus and anterior superior iliac spine
Signs of peritoneal irritation:
Obturator sign: when supine provider rotates right hip with knee flexed
Psoas signs: Patient is supine and tries to raise straightened leg against resistance
Markle sign: have patient jump
Bump sign:
Pain precedes other symptoms and when the symptoms occur in any other order, the diagnosis of appendicitis should be questioned.
Pain is usually of short duration.
A patient reports anal pruritis and occasional bleeding with defecation. An examination of the perianal area reveals external hemorrhoids around the anal orifice as the patient is bearing down. The provider orders a colonoscopy to further evaluate this patient. What is the treatment for this patient’s symptoms?
a. A high-fiber diet and increased fluid intake
b. Daily laxatives to prevent straining with stools
c. Infiltration of a local anesthetic into the hemorrhoid
d. Referral for possible surgical intervention
a. A high-fiber diet and increased fluid intake
Most hemorrhoids, unless incarcerated or painful, are treated conservatively. A high-fiber diet and increased fluid intake are recommended first.
Daily laxatives are not recommended because the variation in stool consistency makes hemorrhoid management more difficult.
Infiltration of a local anesthetic is performed for thrombosed external hemorrhoid prior to removing the clot. Hemorrhoidectomy is performed for severe or very painful hemorrhoids.
What recommendations are appropriate for patients with chronic pruritus ani? (Select all that apply.)
a. Application of a topical antihistamine
b. Applying a of 1% hydrocortisone cream for several months
c. Avoid tight-fitting or non-breathable clothing
d. Avoiding perfumed soaps and toilet papers
e. Using a hair dryer on the cool setting to control itching
c. Avoid tight-fitting or non-breathable clothing
d. Avoiding perfumed soaps and toilet papers
e. Using a hair dryer on the cool setting to control itching
Measures to control itching include avoiding tight-fitting clothing as well as perfumed products and keeping the area clean and dry and using a cool hair dryer to dry the skin.
Topical antihistamines are not used.
Using a topical steroid **longer than 2 weeks causes thinning of the skin.
A patient has sudden onset of right upper quadrant (URQ) and epigastric abdominal pain with fever, nausea, and vomiting. The emergency department provider notes yellowing of the sclerae. What is the probable cause of these findings?
a. Acute acalculous cholecystitis
b. Chronic cholelithiasis
c. Common bile duct obstruction
d. Infectious cholecystitis
c. Common bile duct obstruction
This patient has symptoms of cholecystitis with bile duct obstruction, which causes jaundice.
The common triad of RUQ pain, fever, and jaundice occurs when a stone is lodged in the common bile duct.
Gall stones can be partial or full obstruction symptoms vary dependent on size of stone. typically symptoms occur within 1 hour of eating and can last 1-6 hours. may have diarrhea because obstruction results in blockage of bile which prevents the breakdown of fats. Can lead to infection
Acute acalculous cholecystitis is inflammation without stones.
Chronic cholelithiasis does not cause acute symptoms; jaundice occurs with obstruction.
Infectious cholecystitis may occur without obstruction
A patient presents with fever, nausea, vomiting, anorexia, and right upper quadrant abdominal pain. An ultrasound is negative for gallstones. Which action is necessary to treat this patient’s symptoms?
a. Empirical treatment with antibiotics
b. Hospitalization for emergent treatment
c. Prescribing ursodeoxycholic acid
d. Supportive care with close follow-up
b. Hospitalization for emergent treatment
This patient has symptoms of acute acalculous cholecystitis and is critically ill. Which is inflammation without stones. Hospitalization is required
Empirical treatment with antibiotics and supportive care with follow-up do not address critical care needs.
Ursodeoxycholic acid is a medication that helps with gallstone dissolution; this patient does not have gallstones.
Gall stones can be partial or full obstruction symptoms vary dependent on size of stone. typically symptoms occur within 1 hour of eating and can last 1-6 hours. may have diarrhea because obstruction results in blockage of bile which prevents the breakdown of fats.
Which diagnostic test will the provider safely order for a 30-year-old woman reporting right upper quadrant abdominal pain, nausea, and vomiting?
a. Abdominal computed tomography (CT) with contrast
b. Abdominal ultrasound
c. Magnetic resonance imaging (MRI) of the abdomen
d. Plain abdominal radiographs
b. Abdominal ultrasound
Women of childbearing age may safely have ultrasound. Until pregnancy is ruled out, the other studies may be harmful to a developing fetus and should be avoided.
A patient with a previous history of liver disease is diagnosed with a bile duct obstruction. Which procedure will be prescribed for this patient?
a. Chemical dissolution of the gallstone
b. Lithotripsy
c. Open cholecystectomy
d. Laparoscopic cholecystectomy
c. Open cholecystectomy
Patients with possible liver disease should have open cholecystectomy. The other procedures are contraindicated. Chemical dissolution is not reliable and may take some time.
A patient is diagnosed with fibrotic liver disease; a liver biopsy shows micronodular cirrhosis. What is the most common cause of this form of cirrhosis?
a. Alcoholism
b. Hepatitis C
c. Hepatocellular carcinoma
d. Right-sided heart failure
a. Alcoholism
Micronodular cirrhosis is often associated with alcoholic liver disease. Viral causes and carcinoma usually cause macronodular cirrhosis. Right-sided heart failure occurs with many other causes as part of the disease development.
A patient with a history of chronic alcoholism reports weight loss, pruritis, and fatigue. The patient’s urine and stools appear normal. What do these findings indicate?
a. Early liver cirrhosis
b. Late liver cirrhosis
c. Liver failure and ascites
d. Probably viral hepatitis
a. Early liver cirrhosis
Early symptoms of cirrhosis are characterized by this patient’s symptoms.
As the condition worsens, stools and urine change color and the patient develops anorexia, nausea, and vomiting.
Liver failure and ascites are late and will include abdominal pain.
Viral hepatitis is a less likely diagnosis in the patient with a history of alcoholism.
A patient diagnosed with cirrhosis develops ascites. Which medication will be ordered initially to improve symptoms?
a. Cephalosporin
b. Furosemide
c. Lactulose
d. Spironolactone
d. Spironolactone
Spironolactone is the initial diuretic used to improve fluid diuresis in patients with ascites. Furosemide may be used as adjunctive therapy. Cephalosporin is used when infections occur. Lactulose is used to increase stools and reduce encephalopathy.
A patient diagnosed with chronic constipation uses polyethylene glycol and reports increased abdominal discomfort with nausea and vomiting. What is the initial action by the provider?
a. Increase the dose of polyethylene glycol
b. Obtain radiographic abdominal studies
c. Perform a stool culture and occult blood
d. Refer to a specialist for colonoscopy
b. Obtain radiographic abdominal studies
Patients with abdominal pain, nausea, and vomiting should have radiologic studies to exclude obstruction, ileus, megacolon, or volvulus. d/t similar presenting symptoms either with xray or CT
If those are ruled out, increasing the laxative may be warranted.
Stool culture is indicated if the parasite ascariasis is suspected.
Referral for colonoscopy is needed if alarm symptoms for neoplasm are present.
alarming symptoms = sudden change in bowel habits after the age of 50, blood in stool, anemia and fam history of colon cancer
A patient has recurrent constipation which improves with laxative use but returns when laxatives are discontinued. Which pharmacologic treatment will the provider recommend for long-term management?
a. Bisacodyl
b. Docusate sodium
c. Methylcellulose
d. Mineral oil
c. Methylcellulose = bulk forming laxative
Phase 1 constipation treatment is lifestyle changes: inc 25-30 g of fiber per day gradually, inc fluids, and dec cheese and fats if that does not work then phase 2 is bulk forming laxative (metamucil).
Methylcellulose is a bulk-forming product and is used initially.
The other medications are used for more severe constipation and not recommended for long-term use.
A patient reports a decrease in the frequency of stools and asks about treatment for constipation. Which findings are part of the Rome IV criteria for diagnosing constipation? (Select all that apply.)
a. Feeling of incomplete evacuation
b. Fewer than 5 stools per week
c. Hard or lumpy stools
d. Presence of irritable bowel syndrome
e. Symptoms present for 3 months
a. Feeling of incomplete evacuation
c. Hard or lumpy stools
e. Symptoms present for 3 months
According to the Rome III criteria, symptoms must have begun 6 months prior and persisted for at least 3 months and include a feeling of incomplete evacuation, lumpy or hard stools, fewer than 3 stools per week, and not meeting criteria for irritable bowel syndrome.
A patient, who first developed acute diarrhea 2 weeks ago, presents to clinic reporting profuse
watery, bloody diarrheal stools 6 to 8 times daily. The provider notes a toxic appearance with
moderate dehydration. Which test is indicated to diagnose this problem?
a. Qualitative and quantitative fecal fat
b. Stool collection for 24-hour stool pH
c. Stool sample for C. difficile toxin
d. Wright stain of stool for white blood cells
c. Stool sample for C. difficile toxin
Patients with acute onset diarrhea lasting more than 2 weeks with profuse, watery, bloody, fever
stools of more than 6 times in a 24-hour period and are immunocompromised warrants testing for C. difficile toxin.
Qualitative and quantitative fecal fat, 24-hour pH studies, and Wright stain for WBCs are
performed when chronic diarrhea are present.
A patient who developed chronic diarrhea after gastric surgery asks what can be done to
mitigate symptoms. What will the provider recommend initially?
a. A diet high in carbohydrates
b. Avoiding liquids with meals
c. Empirical antibiotic therapy
d. Probiotic supplements
b. Avoiding liquids with meals
Initial suggestions for treating postoperative diarrhea will include avoiding fluids during
meals and lying down after meals. Concentrated carbohydrates may trigger symptoms.
Empirical antibiotic therapy is indicated for small intestinal bacterial overgrowth syndrome
with specific symptoms and an association with an elevated folate level. Probiotic
supplements may be used as adjunctive therapy.
Which types of chronic noninfectious diarrhea will cause fatty stools? (Select all that apply.)
a. Celiac disease
b. Cystic fibrosis
c. Diabetes mellitus
d. Lactose intolerance
e. Pancreatic insufficiency
a. Celiac disease
b. Cystic fibrosis
e. Pancreatic insufficiency
Celiac disease, cystic fibrosis, and pancreatic insufficiency all produce malabsorption of fats
and will result in fatty stools. Diabetes results in glucose malabsorption, while lactose
intolerance causes lactose malabsorption.
A patient with a history of diverticular disease asks what can be done to minimize acute
symptoms. What will the provider recommend to this patient?
a. Avoiding saturated fats and red meat
b. Consuming a diet high in fiber
c. Taking an anticholinergic medication
d. Using bran to replace high-fiber foods
b. Consuming a diet high in fiber
Diverticula is a pouch-like herniation of external surface of colon r/t lack of dietary fiber can be asymptomatic or symptomatic
main symptom: coliky abdominal pain in an absence of an inflammatory process pain occurring in LLQ
Increasing dietary fiber reduces constipation and reduces the incidence of acute symptoms.
Avoiding saturated fats and red meats does not reduce the risk of diverticulitis but does
decrease the risk of colon cancer.
Anticholinergics and antispasmodics do not prevent attacks but may help with symptoms.
Bran may be used as an adjunct to high-fiber foods but should
not replace other high-fiber sources.
A patient with a history of diverticular disease experiences left-sided pain and reports seeing
blood in the stool. What is an important intervention for these symptoms?
a. Ordering a CBC and stool for occult blood
b. Prescribing an antispasmodic medication
c. Referring the patient for a lower endoscopy
d. Reminding the patient to eat a high-fiber diet
c. Referring the patient for a lower endoscopy
Alarming symptoms of diverticular disease are bleeding, fever and worsening symptoms, changes in bowel habits (diarrhea or constipation) = diverticulitis if not treated can cause perforation and can be life threatening. Need scope
Treatment: not fiber in acute cases, need antibiotics: Augmentin, cipro and flagyl
Patients with suspected diverticular abscess of rectal bleeding need further evaluation and a
referral for lower endoscopy is warranted.
A patient has intermittent left-sided lower abdominal pain and fever associated with bloating
and constipation alternating with diarrhea. The provider suspects acute diverticulitis. Which
tests will the provider order? (Select all that apply.)
a. Barium enema examination
b. Computerized tomography (CT) scan of abdomen and pelvis
c. Plain abdominal radiographs
d. Rigid sigmoidoscopy
e. Stool for occult blood
b. Computerized tomography (CT) scan of abdomen and pelvis
e. Stool for occult blood
For symptomatic diverticulosis, the diagnosis of diverticulosis or segmental colitis (as with
SCAD) can be established by direct view on colonoscopy or flexible sigmoidoscopy. A CT
scan of the abdomen can also diagnose diverticulosis. A barium or water-soluble enema
should not be utilized if acute diverticulitis is suspected. Plain abdominal x-ray films will be
normal and are unnecessary, although they are sometimes ordered to exclude the presence of
free air in the abdomen
An older adult patient has recently experienced weight loss. The patient’s spouse reports
noticing coughing and choking when eating. What is the likely cause of this presentation?
a. Esophageal dysphagia
b. Oral stage dysphagia
c. Pharyngeal dysphagia
d. Xerostomia causing dysphagia
c. Pharyngeal dysphagia
Pharyngeal dysphagia often results from weakness or poor coordination of the pharyngeal
muscles which can cause delayed swallow and failure of airway protection, leading to
coughing and choking. Esophageal dysphagia is associated with pain after swallowing. Oral
stage disorders are related to poor bolus control and result in drooling or spilling. Xerostomia
is when oral mucous membranes are dry.
Which diagnostic study is best to evaluate a swallowing disorder?
a. Computerized tomography (CT) of the head and neck
b. Electroglottography
c. Electron microscopy
d. Videofluoroscopy (VFES)
d. Videofluoroscopy (VFES)
Videofluoroscopy is the most appropriate because it visualizes the actual swallow.
Electroglottography and electron microscopy may be appropriate but are more limited. CT
evaluation may aid in diagnosis but does not describe the actual swallow mechanism
A patient experiences a feeding disorder after a stroke that causes disordered tongue function
and impaired laryngeal closure. What intervention will be helpful to reduce complications in
this patient?
a. Surface electrical stimulation
b. Teaching head rotation
c. Thickened liquids
d. Thinning liquids
c. Thickened liquids
Thickening liquids is helpful for patients with disordered tongue function and impaired
laryngeal closure, because there is a reduced tendency for liquids to spill over the tongue base
and cause aspiration. Surface electrical stimulation helps improve strength of muscles but
does not address the problem of aspiration. Teaching head rotation is used for patients with
unilateral laryngeal dysfunction. Thinning liquids is used for patients with weak pharyngeal contractions
A patient experiences a sharp pain just under the sternum with swallowing. This is more
commonly associated with which condition?
a. Hiatal hernia
b. Infectious esophagitis
c. Peptic stricture
d. Schatzki ring
b. Infectious esophagitis
A sharp, substernal pain with swallowing is most commonly associated with infectious
esophagitis. Esophageal strictures are highly correlated with hiatal hernia and patients with
stricture will report a feeling of food becoming stuck. A Schatzki ring and peptic stricture are
types of strictures.
- Which medications may cause the greatest increase in the prevalence of gastroesophageal
reflux disease (GERD)? (Select all that apply.)
a. Aspirin
b. Benzodiazepines
c. Calcium antagonists
d. Hormone replacements
e. Oral contraceptives
a. Aspirin
b. Benzodiazepines
c. Calcium antagonists
aspirin, benzodiazepines, and calcium antagonists all increase the likelihood of GERD, while
hormone replacement therapy and OCPs are associated with a lower incidence.
A 50-year-old, previously healthy patient has developed gastritis. What is the most likely cause of this condition?
a. H. pylori infection
b. NSAID use
c. Parasite infestation
d. Viral gastroenteritis
a. H. pylori infection
H. pylori accounts for most cases such as gastritis, duodenal ulcers, and gastric ulcers.
NSAID use is an important cause, but not likely in a previously healthy individual. *Will happen with continued use
Parasites are the leading cause worldwide, but not in the United States.
Viral gastroenteritis usually does not cause chronic gastritis and usually has lower GI symptoms.
A patient has both occasional “coffee ground” emesis and melena stools. What is the most probably source of bleeding in this patient?
a. Hepatic
b. Lower gastrointestinal (GI) tract
c. Rectal
d. Upper gastrointestinal (GI) tract
d. Upper gastrointestinal (GI) tract
Coffee ground emesis is usually old blood from an upper GI source and melena is black, shiny, foul-smelling as a result of blood degradation and is usually upper GI in origin.
**will have elevated BUN/CReat
Lower GI and rectal bleeding will cause bright red blood in stools. hematochezia
**will have normal BUN/creat
Hepatic bleeding usually does not affect the GI tract.
What initial action is appropriate when admitting a patient who has a gastrointestinal (GI) tract bleed, hypotension, and a hematocrit decrease of 6% from baseline?
a. Administer packed red blood cells.
b. Place a Foley catheter to monitor output.
c. Place two large-bore intravenous lines.
d. Prepare for surgical repair of the bleed.
c. Place two large-bore intravenous lines.
Vitals signs are most important sign of bleed: Tachy is early sign hypotension is late. CBC (looking at RBCs, platelets, hgb and hemat =determine amount of blood loss)
The first interventions should involve restoring circulatory status to normal in patients with hypotension and low hematocrit. Placement of two large-bore intravenous lines or a central line is essential to allow transfusions of PRCs and fluids (LR or NS).
The other interventions will be carried out but are not the initial action.
A patient who is asymptomatic tests positive for the hepatitis C virus (HVC). What will the provider tell the patient about managing this illness?
a. A rapidly fulminant disease ending with cirrhosis is likely.
b. Administering immunoglobulins helps shorten the course.
c. Several medications are available based on the type of hepatitis C.
d. Treatment is supportive since the infection is self-limiting.
c. Several medications are available based on the type of hepatitis C.
hep c: common mode of transmission IV drug use no vaccine can lead to chronic liver disease
The provider should inform the patient that there are several medications available based on the type of hepatitis C the patient has. HCV rarely has a rapidly fulminant course, although cirrhosis is likely after years of infection.
Immunoglobulin therapy is given for HBV. The disease is not self-limiting* Hep b will also have serum surface antigen as diagnostic test
Which form of hepatitis virus is rapidly spread via the fecal-oral route?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D
a. Hepatitis A
sx of hepatitis: mailaise, n/v/d, fever, fatugue, dark urine clay colored stools, RUQ pain, jaundice (50%)
HAV is rapidly spread, usually through contaminated food, through the fecal-oral route. Diagnostic test= antibody test self-limiting
HBV: from blood, sexual activity: treated with Immunoglobulin therapy. It has a vaccine that is given at birth, 1 months and 6 months
may have rash with hep b
A patient recovering from chronic alcohol abuse reports nausea, vomiting, diarrhea, and abdominal discomfort. A physical examination is negative for jaundice or ascites. What will
the provider do initially?
a. Obtain a bilirubin level and prothrombin time
b. Order a complete blood count and liver function tests
c. Reassure the patient that this is likely a viral gastroenteritis
d. Refer the patient to a specialist for evaluation and treatment
b. Order a complete blood count and liver function tests
Patients with alcoholic hepatitis may present initially with signs of gastroenteritis. Based on the history, even without jaundice and ascites, the provider should order a CBC and LFTs.
Bilirubin and PT levels are performed when a diagnosis is made to determine prognosis and course of the disease. Reassuring the patient without confirmation of disease is not recommended. Referral is made if hepatitis is diagnosed.
