Module 8

Question 1

what is urinary incontinence?

Answer 1

involuntary intermittent or perisistent loss of urine

Question 2

urinary incontinence is a normal sign of aging T/F

Answer 2

false, urinary incontinence is abnormal in all ages

Question 3

what are some risk factors of urinary incontinence?

Answer 3

impaired mobility, pelvic floor weakness, race, ethnicity, weight, frequent UTIs, BPH, medications

Question 4

discuss the pathophysiology behind urinary incontinence

Answer 4

usually because of an underlying sphincter or bladder problem, could also be extrinsic (ie related to meds) that can be easily treated, could also be underlying neurological problem

Question 5

what is stress incontinence?

Answer 5

leakage of urine due to increased intra-abdominal pressure, pressure in abdomen increases pressure on sphincter which causes urethral opening and leakage

can be classed into: anatomic (hypermobility of the bladder neck, bladder neck works but overly active ie-sphincter will close and open) or intrinsic (bladder neck is always open

Question 6

what is urge incontinence

Answer 6

most common in older adults
uncontrollable sensation to void

can be caused by detrusor overactivity (detrusor muscle -musculature that stretches to contain urine; unknown causes) or poor bladder compliance (inability to store large amounts of urine, little amount causes increased pressure)

Question 7

what is overflow incontinence

Answer 7

incomplete emptying of the bladder; urine builds because of incomplete emptying and leakage occurs

Question 8

discuss management therapies for stress incontinence

Answer 8

behavioural therapies- timed/double voiding to ensure emptying of the bladder
smoking cessation- increases coughing and increases urgency
pelvic floor muscles- strengthen pelvic floor and urethra to prevent leaks during increased pressure

medical therapies - alpha adrenergic agonists (pseudoephedrine) increases urethral pressure
estrogen replacement for post menopausal related atrophic vaginitis
tricyclic antidepressants
caution meds in older adults for anticholinergic effects

Question 9

discuss management therapies for urge incontinence

Answer 9

behavioural- timed/double voiding, smoking cessation, pelvic floor, weight reduction
bladder training - postpone urinating and waiting, use of kegels during urge to alleviate urge symptoms

medical therapies- antimuscarinic agents (oxybutynin)

Question 10

discuss management therapies for overflow incontinence

Answer 10

timed/double voiding
may introduce intermittent catheterization (reserve for those who have poor emptying and are not surgical candidates)

medications can be used-those for BPH

Question 11

complications of urinary incontienence

Answer 11

infections, sleep interruption, mental health, sexual dysfunction, poor social esteem

refer to specialist if incontinence type is unknown

Question 12

What are the common causes of erectile dysfunction?

Answer 12

difficulty or inability to enjoy intercourse or disorder that interferes with sexual response, persistent inability to achieve and maintain an erection

younger populations with ED can lead to greater risk of CV events
higher incidence in those with neurological, endocrine, cancer, PTSD survivors

Question 13

What are the clinical manifestations of erectile dysfunction?

Answer 13

broad history-may ilicit onset of concerns
discuss previous medical history that may contribute to ED
predisposing factors (relationships, trauma, upbringing)
precipitating factors (discordant relationships, depression/anxiety, medical conditions)
maintaining factors (performance, relationships, impaired self image, communication problems)

Question 14

What are strategies to manage erectile dysfunction?

Answer 14

HCP discussing sexuality
determine cause of ED- organic, psychological, relational
counselling, anxiety reduction techniques

pharm: testosterone replacement, oral PDE5 (sildenafil, tadalafil) contraindicated in those taking nitrate medications)
tadalafil longer lasting than sildenafil (s/e: headache, flushing, nasal congestion, dyspepsia)
penile injections, pumps, penile prosthesis

Question 15

Identify epidemiological factors of testicular cancer.

Answer 15

testicular cancer is uncommon, approx 1% of population
occurs in males aged 20-39, most common cancer in males aged 15-34
caucasian at greater risk
unknown reason for tumour cause; could be trauma, atrophy, increased estrogen exposure, family history, undescended testicle (increases risk)

Question 16

What are some clinical manifestations that may indicate testicular cancer

Answer 16

abnormal mass felt by patient
may have edema, sensation of fullness or heaviness in scrotum
back, abdominal pain, nausea, anorexia, bowel or bladder symptoms may indicate metastatic disease

Question 17

What are the diagnostics used to confirm testicular cancer/tumour

Answer 17

serum tumour markers (hCG, AFP, LDH) - all may be elevated in tumour
ultrasound used to determine size, locations of the mass
additional radiographs should be used if mets is suspected

Question 18

What is useful to distinguish BPH from prostate cancer?

Answer 18

similar signs and symptoms (urinary hesitancy, nocturia, hematuria)

prostate cancer- symptoms increase in intensity in 1-2 months, may progress to back pain, impotence and bone pain (mets)

DRE and PSA may not be enough to indicate BPH or prostate cancer

biopsy is useful in determining malignancy

Question 19

describe the difference between cholelithiasis and cholecystitis

Answer 19

formation of gallstones and then bladder inflammation

gallstones may be asymptomatic, doesn’t necessarily turn into cholecystits

Question 20

what is the pathophysiology behind cholelithiasis and cholecystitis?

Answer 20

gallstones are bile crystals formed in the gallbladder, crystals vary in size-smaller ones often pass through bile duct and are excreted

larger stones can block bile duct
lack of bile= no fat breakdown, fats pass into larger intestine, changes osmality of large intestine
continued blockage causes inflammation

Question 21

what are the clinical manifestations of chole?

Answer 21

epigastric, RUQ pain, nausea and vomiting (contractions from the gallbladder trying to pass stone)
pain worsens after eating esp fatty foods

fever, jaundice in cholecystitis

Question 22

what are the physical findings in a patient with chole

Answer 22

tenderness and pain to RUQ during palpation
rigidity, muscle guarding due to pain
Murphy’s sign present (pushing on RUQ and pt unable to take a breath)
radiating pain may be present

Question 23

how do you manage a patient with cholecysitis?

Answer 23

refer to ER
if asymptomatic-no need for referral
ultrasound is most sensitive diagnostic tool to confirm stones
liver enzymes, blood work (bili, AST, alk phos may be elevated)

Question 24

What is acute pancreatitis? How is it different from chronic pancreatitis?

Answer 24

inflammation of the pancreas (mild to severe)
causes: most common from gallstones, trauma, alcohol, hyperlipidemia, infection
able to recover in acute pancreatitis, acute pancreatitis does not cause long term pancreatic insuffiencient
chronic is permament cell changes of the pancreas affecting endocrine function

Question 25

what are some of the risk factors for gallstone formation?

Answer 25

occurs in middle aged population >40 years of age ethnicity-indigenous at greater risk females during pregnancy family hx, obesity, medications (contraception), alcohol, diabetes

Question 26

what are the clinical manifestations of pancreatitis?

Answer 26

``` abdominal, epigastric pain can refer to back or chest, rebound tenderness nausea/vomiting not relieved with food, actually worsens weight loss, steatorrhea ``` chronic pancreatitis- endocrine dysfunction, symptoms of diabetes

Question 27

what are the primary causes of chronic pancreatitis?

Answer 27

alcohol (most common cause, 50-70%) duct obstruction- tumours, trauma metabolic causes- hypercalcemia, hyperlipidemia genetic/environmental/medical conditions

Question 28

a 37yr old presents with symptoms of pancreatitis, what other condition should be evaluated?

Answer 28

cystic fibrosis- can increase risk of pancreatic insufficiency

Question 29

what are red flags that warrant immediate pancreatic cancer investigation?

Answer 29

``` >50 years of age new onset of DM changes in bowel habit no ETOH use weight loss insidious symptoms (fatigue, malaise, insomnia) ```

Question 30

what levels of amylase and lipase would you expect to find in a pt with acute and chronic pancreatitis?

Answer 30

acute- increase in both amylase and lipase | chronic-no increase in amylase and lipase because cell levels are low due to cellular changes

Question 31

discuss some management techniques in a pt with chronic pancreatitis

Answer 31

pain control-short term opiates nutritional- lipase, enzyme supplements, vitamin supplements to aid in fat breakdown surgery- stent, shock wave if stones present

Question 32

what is the diagnostic criteria for chronic kidney disease?

Answer 32

loss of filtration of blood and increase of waste products in the bloodstream CKD considered when kidney structure is impaired or abnormal for >3 months, GFR usually <60mmol

Question 33

what are the largest risk factors for CKD?

Answer 33

HTN, DM, CKD | family hx of CKD

Question 34

what are the recommended screening requirements for CKD

Answer 34

screening eGFR, creatinine, UACR at risk populations: q1-2 years DM q1 year one incident of abnormality doesn't mean abnormal kidney function

Question 35

what factors can contribute to changes in eeGFR?

Answer 35

low body weight, diet, infections, medications, amputees, >75 years of age

Question 36

discuss management strategies in a patient with CKD

Answer 36

avoiding factors that can cause AKI (med adjustments, avoiding nephrotoxic meds, avoid contrast dye) BP monitoring (<140/90) -ACEi or ARB q6 month b/w, increasing increments if changes in medical status UACR q 6-12 months potassium levesl <5.5 CVD risk assessments, statins if needed DM monitorinng, avoid metformin or sulfpnylreas if GFR is unstable weight/nutritio smoking cessation health maintenance, psychosocial heatlh

Question 37

What medications are contraindicated in those with CKD? What are some common drugs that need to be adjusted in those with renal insufficiency?

Answer 37

nephrotoxic medications need to be avoided NSAIDs, COX inhibitors, aminoglycosides no IV contrast dyes ``` allopurinol wellbutrin lithium codein valcyclovir ```

Question 38

What are some clinical presentations requiring surgical consultation for evaluation of abdominal pain?

Answer 38

appendicitis - pain in RLQ, abdominal rigidity, migrating pain from epigastrium, nausea/vomiting, fever presence of mcburneys (pain to RLQ during palpation), rosvig (pain to LLQ during palpation), psoas (R leg raise illicits pain) obturator (rebound tenderness when knee flexed and raised) perforated peptic ulcer - abrupt onset of sever pain, radiating abdominal pain from epigastrum, coffee ground emesis, hematemesis, melena stools, hematochezia bowel obstruction - intermitted crampy abdominal pain, vomiting, fever, hyperactive bowel sounds, increased gas and flatulence peritonitis - high fever, acute abdominal pain, tendeness, nausea, vomiting, diarrhea/constipation aortic aneurysm- painful bulging mass to abdomen

Question 39

what are risk factors that can cause GI bleeding?

Answer 39

NSAIDS, smoking, increased acid production, H pylori infection, trauma

Question 40

how is upper and lower GI bleeding differentiated?

Answer 40

according to the anatomic source, upper-proximal to ligament of treitz (right before the start of the small intestine, includes the stomach)

Question 41

how is upper GI bleeding classified and what are some of the conditions in each classification?

Answer 41

variceal and non-variceal classifications variciel- esophagitis, varices non variceal- PUD, gastric ulcers, erosions, use of NSAIDs

Question 42

what are the clinical manifestations of upper and lower GI bleeds?

Answer 42

can be asymptomatic with vague symptoms hematemesis (bloody vomitus), melena stools (black, foul smelling stool) - usually originates from an upper GI source hematochezia (bright red stools) usually from lower GI source

Question 43

what is the most common cause of lower GI bleed?

Answer 43

diverticulitis (inflammation of the diverticula) - trapped feces or particles causes inflammation, can lead to necrosis, inappropriate breakdown of foods

Question 44

what are some diagnostic tools used for upper and lower GI bleed?

Answer 44

cbc diff stool occult blood electrolytes LFTs, creatinine may use imaginging -abdo CT scan, ultrasound

Question 45

how would you manage a patient with a GI bleed?

Answer 45

1. ensuring hemodynamic stability in case of severe blood loss ie) transfusions, fluid replacement 2. reversing anticoagulants if the cause of bleeding 3. pharmacological interventions (PPIs for upper GI bleed due to PUD) 4. endoscopy to determine source of upper GI bleeding (most accurate diagnostic tool) 5. LGIB- colonoscopy

Question 46

what are common clinical manifestations that may indicate esophageal conditions?

Answer 46

heartburn (substernal burning, radiating to neck)- usually a sign of GERD dysphagia (difficulty swallowing, feeling like it won't go down)- mechanical/neurological disruptions, brainstem lesions, GERD, PUD odynophagia (sharp pain with intake of food)- usually associated with esophageal esophagitis, infection in immunocompromised patients

Question 47

what is peptic ulcer disease? who is at risk?

Answer 47

ulceration of gastric or duodenal mucousa; usually caused by H. Pylori or increased NSAID use family hx, smoking, steroids, ETOH, biphosphonate therapy increases risk of PUD

Question 48

what is the patho behind PUD?

Answer 48

acid and pepsin needed to break down food, alkaline used to protect the stomach lining h.pylori (oral fecal route) causes inflammation and erodes stomach lining . NSAIDS blocks prostagladins responsible for protecting the coating of the stomach

Question 49

what is the clinical presentation of someone with PUD?

Answer 49

often asymptomatic epigastric pain, dyspepsia common sharp gnawing pain occurs 2-4 hours after eating a meal pain is often alleviated right away with food/antacids

Question 50

what tests are required to diagnose someone with PUD

Answer 50

cbc diff stool cultures H. pylori serology or breath test endoscopy is the most accurate

Question 51

what are some red flags that warrant immediate evalation in a person presenting with abdominal pain?

Answer 51

``` vomiting abdominal mass blood stools weight loss dysphagia >50 years of age ```

Question 52

what is celiac disease and who is at risk?

Answer 52

immune response to gluten, intake causes inflammation and damage to small intestine leading to malabsorption unclear who is at risk, genetic mutation (HLA DQ2) symptoms occur for approx 10 years before idnentification, usually diagnosed in adulthood

Question 53

what are clinical manifestations of celiac disease

Answer 53

malabsorption, weight loss, diarrhea, steatorrhea, weakness and flatulence atypical symptom: dermatitis herpatiform- cutaneous variant of celiac disease, pruritic papulovesicles over trunk, scalp and neck

Question 54

what serology test is used to diagnose celiac disease

Answer 54

IgA TGA antibody testing, 98% sensitive

Question 55

what are some management strategies in someone with celiac disease?

Answer 55

remove all gluten from diet assess diet and medications that may use gluten preservatives usually symptoms resolve in 1-2 weeks of no gluten, excellent prognosis

Question 56

what is IBS and who is at risk?

Answer 56

very common in primary care functional GI disorder d/t no pathology or concerns with GI tract, no identifiable cause of IBS more common in women than men, occurs later stages of life in 30-40s

Question 57

what is the diagnostic criteria for IBS?

Answer 57

abdo pain/discomfort for at least 3x per week in the last 3 months + improvement with defecation, change in frequency of stool, change in appearance of stool no underlying pathology for symptoms

Question 58

what are some management strategies in someone with IBS?

Answer 58

dietary modifications, increase fibre, probiotoics. avoiding triggering foods antispasmotics, antidiarrheals, psychotropic drugs if anxiety related

Question 59

what symptoms are incompatible with a diagnosis of IBS and warrant immediate evaluation?

Answer 59

``` nocturnal symptoms bloody/greasy stool weight loss malnutrition GI bleeding recurrent vomiting anemia fever ```

Question 60

what is the primary difference between IBS and IBD?

Answer 60

IBS-functioning GI disorder with no underlying pathology | IBD- inflammatory disorders with underlying pathology; divided into Chron's and ulcerative colitis

Question 61

what are the major risk factors of UC and CD?

Answer 61

genetics as significant cause of IBD- genetic mutations as a predictor of changes in the gut microbiome CD has a poorer prognosis tobacco smoking as the primary environmental cause of IBD

Question 62

what part of the digestive tract does UC and CD affect? what are the clinical manifestations?

Answer 62

UC- rectum and colon CD- any part of the digestive tract, most commonly found in the small intestine similar clincal presentations, may be difficult to diagnose abdominal pain-diffuse to LLQ or RLQ, cramping sensation bloody stools (more often in UC) vague symptoms in CD, fatigue, weight loss, anorexia CD can lead to fissures, obstruction, fistulas

Question 63

what is the diagnostic tool for CD or UC?

Answer 63

endoscopy is more accurate in determining UC or CD- cobblestone appearance of mucousa in CD

Question 64

what pharmacological options are available for those with UC or CD?

Answer 64

mesalamine (helpful in UC) corticosteroids biologics surgery (for CD)

Question 65

what are the modes of transmission for Hep A, B and C

Answer 65

HAV: fecal oral route, contaminated water/foods, blood transfusions HBV: bodily fluids ie) blood, seminal fluid, mother to fetus HCV: blood and parenteral routes

Question 66

what are the risk factors for Hep A B and C

Answer 66

HAV: more prevalent in areas with low socioeconomic status, poor sanitation and poor drinking water, common in Asia, Africa, South America HBV: IVDU, tattoos, risky sexual behaviours, correctional factilities, HIV, HCV, HCPs HCV: baby boomers, IVDU, HCPs, multiple sexual partners, tattoos

Question 67

what are the clinical manifestations and incubation periods of HAV, HBV, HCV

Answer 67

HAV: acute infection, malaise, anorexia, jaundice, nausea, fever, symptoms appear after 4 weeks of virus acquisition incubation period 2-6 weeks no carrier state in HAV, body can rid virus itself HBV: often asymptomatic, malaise, anorexia, jaundice, nausea, symptoms appear 6 weeks after exposure incubation period 2-6 months chronic carrier due to ongoing viral repetition HCV: may be asymptomatic, anorexia, malaise, JAUNDICE IS RARE, chronic carrier, incubation period 2-22 weeks

Question 68

what diagnostic tests are used to assess hepatitis?

Answer 68

cbc, diff, LFTs, antibodies, antigens HCV RNA if positive HCV antibody previous antibodies can be because of previous vaccination or infection