Module 4 Flashcards
most common mode of transmission for acute infectious gastroenteritis is
the fecal–oral route from contaminated food or water.
Numerous fecal leukocytes in patients with acute diarrhea is indicative of
diffuse colonic inflammation and is highly suggestive of an invasive pathogen such as Shigella, Salmonella, or Campylobacter.
A stool culture should be done on any patient who
has severe diarrhea, a fever of 101.3°F (38.5°C) or higher, the presence of bloody stools, or stools that test positive for leukocytes, lactoferrin, or occult blood
if persistent diarrhea
examine stool for ova or parasites
Viral gastroenteritis should be suspected in patients who present with
vomiting as the major symptom and in cases where food- or waterborne contamination is suspected and the incubation period is greater than 12 hours
gastroenteritis fluid replacement
sodium content 45-75 mEq
gastroenteritis diet
calories come from boiled starches, cereal to facilitate enterocyte renewal
ABX gastroenteritis
only if positive leukocytes
hepatitis types
ABCDE chronic
HAV cause
contaminated water or food
fecal oral
no chronic cases
HBV cause
direct contact with infected blood, blood products, sexual contact
HCV
genotype 1 most common
percutaneous exposure to blood
chronic cases common
HDV
requires hbv for replication
HEV
transmitted fecal oral route
not as easily transmitted as HAV
chronic hepatitis
elevated AST, ALT for more than 6 months
85% of people with HCV
prodromal phase hepatitis
abrupt or insidious onset with anorexia, n/v, URI, flu symptoms
fever
abdominal pain mild and RUQ
icteric phase
jaundice, dark urine 5-10 days after initial symptoms
convalescent phase
increased sense of well being
hallmark of all forms of acute hepatitis
elevated aminotransferase levels
hep tx
supportive
restrict activity
appendicitis
RLQ pain (begins as vague pain, then periumbilical then RUQ)
fever
if pt with RLQ pain presents with shaking chills
suspect perforation of appendix
appendicitis abx
third gen cephalosporins (gentamicin, clindamycin)
In most patients, the normal resting or baseline LES pressure is
10 to 30 mm Hg
In patients who have severe disease, the LES is incompetent, with a resting pressure of
less than 10 mm Hg
Barrett’s epithelium
he body replaces the normal squamous epithelium with metaplastic columnar epithelium (Barrett’s epithelium) containing goblet and columnar cells. This new epithelium is more resistant to acid and, therefore, supports esophageal healing. Barrett’s epithelium is a premalignant tissue, however, and confers a 40-fold increased risk for the development of esophageal adenocarcinoma
gerd lifestyle mods
weight loss (moderate level of evidence); elevating the head of the bed 6 to 8 inches and avoidance of meals 2 to 3 hours before bedtime (low level of evidence); and avoidance of certain foods known to trigger reflux (chocolate, alcohol, caffeine, acidic or spicy foods)
PPIs
trial for 8 weeks
taken 30-60 min before meals
peptic ulcer dx
penetrates the muscularis mucosa and is usually larger than 5 mm in diameter.
damage from PUD is caused by
h pylori or
Nsaids
PUD ulcer location
mostly duodenum, within 3 cm of pylorus
hallmark of PUD
burning or gnawing senesation relieved by food or antacids
PUD tx
PPI, H2RA,
h pylori tx
The standard triple-drug therapy is the combination of two antibiotics (clarithromycin and either amoxicillin or metronidazole) with a PPI all twice a day for 14 days
Internal hemorrhoids most often present with
rectal bleeding described as bright red streaks on the toilet paper.
hemorrhoid tx- lifestyle
directed at decreasing straining with defecation and modification of toilet habits. Patients are encouraged to avoid sitting on the toilet for long periods of time, to use some form of bulk-forming laxative, and to increase their daily fiber intake slowly to 25 to 35 g to establish regular, formed stools
hemorrhoid tx meds
topical hydrocortisone cream
most common type of hernia
groin ( indirect inguinal)
shutter mechanism
, whereby the internal oblique muscle and the transversus abdominis muscles contract to overlap, strengthening the posterior wall of the inguinal canal
closure or sphincter-type mechanism causes contraction
of the musculature, displacing the transversalis fascia, which in effect decreases the diameter of the deep inguinal ring.
indirect inguinal hernia
tissue herniates through the internal inguinal ring, which in men extends the length of the spermatic cord. With continued pressure, the sac can reach the scrotum, where it is then palpable just proximal to Hesselbach’s triangle
IBS definition
two of the following features must be present: abdominal pain or discomfort that is relieved by defecation; change in frequency in stool; and a change in the appearance of the stool.
IBS presentation
LLQ pain, sharp/burning or ache, precipitated by eating, relieved with BM
IBS lifestyle mods
high fiber regardless of initial presentation
hydration
probiotics
ibs med tx
antidiarrheal short term only
dicyclomine (antispasmodic) for abdominal pain
TCAs
Celiac dx
may be asymptomatic
diarrhea, weight loss, dyspepsia, flatulence
celiac dx lab
anti-tTG igA antibodies
bowel obstruction
sudden onset of colicky abdominal pain accompanied by n/v- intermittent and corresponds with perstaltic waves
brown feculent type emesis
diarrhea
observe for areas of previous abdominal sx
dx of bowel obstruction
XR
diverticular dx cause
? low fiber diet implicated
diverticular dx presentation
LLQ abdominal pain
pain worse after eating
diarrhea, constipation alternating
diverticulitis presentation
fever, chills, tachycardia, llq abdominal pain
diverticulitis dx
CT with oral contrast
mild diverticulitis tx
rest, clear liquid diet
abx for diverticulitis
amoxicillin and clavulanate potassium bid x7-10 days
IBD types
ulcerative colitis, crohn’s dx
UC stool characteristics
blood, purulent mucus diarrhea
UC presentation
abdominal cramps relieved with defecation, blood and mucus in stool
CD presentation
abdominal cramping, tenderness, fever, anorexia, weight loss, spasm
acute UC dx
sigmoidoscopy, colonoscopy only when improvement or tx begun
UC tx
nutrition counseling- avoid caffeine, raw fruits, veggies, other foods high in fiber
steroid enema/foam nightly x2 weeks
advanced: systemic glucocorticoid with other therapy
crohns tx
oral prednisone daily
sulfasalazine
immunosuppressive tx
colorectal ca
2nd leading cancer killer in USA
risk factor colorectal ca
age is most important
The physiology of micturition involves three major components of urine storage and release:
the central nervous system (CNS), the bladder, and the bladder outlet (urethral sphincters).
during physical exam for UI, monitor for
CHF- 50% of pts with CHF have UI
UI Dx tests
UA with cx
postvoid residual
Stress incontinence
is the involuntary loss of urine resulting from increased intra-abdominal pressure, such as that caused by coughing, sneezing, and laughing
stress incontinence tx
pelvic floor ed
electrical stim
weight loss
eliminate diuretics
urge incontinence
involuntary leakage of urine resulting from an inability to delay voiding. The patient has the sensation of a full bladder but is not able to store the urine long enough to reach the toilet
urge incontinence tx
pelvic floor tx
scheduled or prompted voiding
overflow incontinence
involuntary leakage of small amounts of urine
Credé’s maneuver
involves applying pressure over the symphysis pubis and slowly pressing down. This is particularly helpful in patients who have a spinal cord injury or other neurologic problems.
use in overflow incontinence
most common cause of uti
e coli
uncomplicated uti tx
3 day course of TMP-SMX or 10 days ampicillin
alternatively, 7 days macrobid
pyelonephritis presentation
triad: fever, CVA pain, N/v
pyelonephritis f/u
48 hours after initial tx to assess response
nephrolithiasis types
calcium salt (most common)
struvite
uric acid
cystine
kidney stone risk factor
sedentary lifestyle
occupation with high environmental temps
kidney stone presentation
renal colic (pain that isn’t relieved with position changes)
nausea, urinary frequency, vomiting, diaphoresis
kidney stone tx
hydration
pain management- NSAIDs, narcotics
acute kidney injury definition
AKI is defined when one of the following criteria is met: serum creatinine rises to 26 mol/L or more within 48 hours or 1.5-fold or greater from the reference value, which is known or presumed to have occurred within 1 week, or urine output is less than 0.5 mL/kg/h for more than 6 consecutive hours
major risk factor for AKI
surgery
Prerenal azotemia is
any condition that leads to an overall decrease in renal perfusion; etiologies in this group include hypovolemia, renovascular disease, decreased cardiac output, systemic vasodilation, renal vasoconstriction, and impairment of renal autoregulation of blood flow, which is often associated with drugs such as ACE inhibitors or NSAIDs
Intrarenal azotemia
refers to disorders that affect the renal parenchyma itself, such as glomerulonephritis, acute tubular necrosis (ATN) (often caused by ischemic insult or nephrotoxic drugs such as aminoglycosides), interstitial nephritis (often an allergic reaction to various drugs or transfusion reactions), and tubular obstruction
Postrenal azotemia
refers to any etiology that might lead to an obstruction of urine flow from the kidneys, including ureteral obstruction, bladder neck obstruction, or urethral obstruction. Major causes include benign prostatic hyperplasia/hypertrophy (BPH), prostate or bladder cancer, and metastatic disease affecting the urinary tract.
no-reflow phenomenon.
Renal blood flow can be reduced by 50% after an ischemic episode; this is termed the
reperfusion injury.
The formation of free radical reactive oxygen species further exacerbates cellular damage and apoptosis (programmed cell death) during reperfusion after a prolonged renal ischemic event, an event termed
Clinical indications of ANT
oliguria (less than 500 ML urine daily)
decreased urea excretion, elevated BUN, elevated creat
reasons why kidney suspectible to toxic damage
Blood continuously circulates through the kidney, repeatedly exposing the tissues to all substances carried by the blood. Also, the kidney is the major excretory organ for toxic substances, and, as these substances await transport within renal cells, they disrupt cellular function
symptoms of AKI
Not present until GFR is 10-15% of normal
fatigue, malaise, n/v, pruritus, mental status change
initiating stage
begins when the kidney is injured; this stage is variable in length, from minutes to several days (e.g., renal damage caused by contrast dye may occur within 2 minutes). Decreased urine volume and other signs and symptoms of renal impairment may then become evident. These may include anorexia, lethargy, nausea, headache, muscle cramps, and fatigue
oliguric stage
usually lasts from 5 to 15 days but can persist for weeks, depending on the nature of renal damage. Renal repair begins as tubular cells regenerate. The destroyed basement membrane is replaced with fibrous scar tissue, and nephrons become obstructed with a build-up of inflammatory products
diuretic stage
, defined as beginning when urine output increases to greater than 400 mL per day and BUN begins to fall. This stage is considered to last until the BUN level stabilizes or is in the normal range and may take from 1 to 2 weeks
recovery phase
, extends from the time BUN stabilizes and urine output returns to normal to the day the patient returns to normal activity. This recovery process may take up to 10 months or more, and some patients never recover but instead progress to CRF
The major underlying conditions leading to ESRD are
diabetes mellitus and primary hypertension seen in approximately 70% of cases,
Malignant nephrosclerosis is associated
with marked hypertension, headache, congestive heart failure, and blurred vision. Unlike the progression of benign nephrosclerosis, renal failure develops rapidly in malignant nephrosclerosis.
Stage 1 CKD
Stage 1 disease is characterized by persistent albuminuria with a normal GFR greater than 90 mL/min per 1.73 m2 of BSA.
Stage 2 CKD
Stage 2 disease is characterized by albuminuria with a GFR between 60 and 89 mL/min per 1.73 m2 of BSA
Stage 3 CKD
Stage 3 disease is defined as a GFR between 30 and 59 mL/min per 1.73 m2 of BSA.
Stage 4 CKD
Stage 4 disease is defined as a GFR between 15 and 29 mL/min/1.73 m2 of BSA
Stage 5 CKD
Stage 5 disease is ESRD, defined as a GFR less than 15 mL/min/1.73 m2 of BSA
baseline DI for CKD
US kidneys
Given the importance of maintaining renal perfusion in CKD
systolic BPs lower than 110 mm Hg should be avoided
CKD diet
2L water/day, 2g sodium/day, restricted protein
renal tumor symptoms
dull, achy flank pain, abdominal mass
weight loss, fatigue
bladder tumor symptoms
frequently asymptomatic, hematuria
hallmarks of major depression, however, are
sadness and anhedonia (loss of pleasure)
peripartum depression
1-3 weeks after birth
PPD
During pregnancy, or up to 4 weeks after delivery
Risk: hx of depression, unplanned pregnancy, preterm birth
criteria for major depressive episode
require 5 or more symptoms having been present during same 2 week period
Definition of depression remission of symptoms
50% decrease in PHQ9 score
initial therapy for moderate-severe depression (meds)
sertraline, escitalopram
Bipolar Disorder I
Bipolar Disorder I: Patients with BD I have had at least one episode of mania. A major depressive episode is not required for diagnosis.
Bipolar Disorder II
BD II is characterized by a history of both depression and hypomania.
Cyclothymic Disorder
: Cyclothymia involves 2 years of symptoms of hypomania and depression that do not meet the full criteria for either mood episode.
Treatment options for patients with BD I with hypomania, mania, or mixed episodes should begin with
lithium, valproic acid (Depakote), or atypical antipsychotic agents
Lamotrigine is effective for patients who predominantly have had
depressed episodes
gold standard for treatment of BD and has been shown to be uniquely effective in decreasing suicidal behavior
lithium
tenth leading cause of death in USA
suicide
Parasuicidal behavior describes patients who
injure themselves in nonlethal, ocassionally attention-seeking gestures, such as superficial cuts on wrists, but who do not wish to die. The behavior is a risk factor for suicide.
The best predictor of suicide risk is a
history of a previous suicide attempt
Generalized anxiety disorder (GAD) is characterized by
excessive worry (over 6 months) about multiple concerns that are difficult to control.
Autonomic hyperactivity is
commonly manifested by excessive sweating, various gastrointestinal symptoms (increased acidity, nausea, and epigastric pain), palpitations, concentration problems, tachycardia, headaches, and shortness of breath
panic disorder age peaks
Panic disorders typically appear in late adolescence or young adulthood, with a peak at 25 years of age. There is a second peak between 35 and 44 year
PTSD symptom categorization
re-experiences traumatic event, avoidance symptoms, negative thoughts/feeling, hyperarousal symptoms for at least 1 month
PTSD meds
paroxetine, sertraline
