Residency Flashcards
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GERD
Treatment
- Proton Pump Inhibitor - compliance.
- Lifestyle modifications.
- H2 Receptor blocker added at night.
- Double dose of PPI or switch to another PPI.
- Baclofen.
- Endoluminal gastroplication.
- Antireflux surgery.
- Pro motility drugs.
- Pain Modulators - SSRIs, TCAs, Trazadone.
GERD
Evaluation
- Upper endoscopy.
- pH testing.
- Bilitec 2000 - DGER, bilirubin as a surrogate marker.
- Esophageal Impedance and pH Monitoring.
Occult Gastrointestinal Bleeding
Manifestations
- Fecal occult blood.
- Iron deficiency anemia.
Extremely common. Can be caused by virtually any lesion in the GI tract.
Iron deficiency anemia in men and post menopausal women.
Cause?
It should be considered to be gastrointestinal blood loss and evaluation by EGD and colonoscopy is required in this setting
Obscure gastrointestinal bleeding.
Location?
Evaluation?
Obscure GI bleeding is by definition recurrent and accounts for approximately 5 % of all cases of GI bleeding.
It usually occurs from a lesion in the small intestine.
Capsule endoscopy and deep enteroscopy (double balloon enteroscopy, single balloon enteroscopy and spiral enteroscopy) are the investigative procedures of choice.
Hepatic Encephalopathy: Long-term treatment
Drugs approved by the FDA
- Lactulose: 15 - 30 ml three times a day. Titrate to achieve 2 - 3 bowel movements a day.
- Rifaximin: 550 mg twice a day.
Hepatic Encephalopathy
Classification
Type A: Associated with acute liver failure.
Type B: Portosystemic bypass with no intrinsic hepatocellular disease.
Type C: Cirrhosis, portal hypertension, portosystemic shunts.
- Episodic HE: precipitated, spontaneous, recurrent.
- Persistent HE: mild, severe, treatment dependent.
- Minimal HE
Patient presenting with iron deficiency anemia and high eosinophils on differential white blood cell count…
Diagnosis?
Hookworm…
Ancyclostoma duodenale
Necator americanus
Inpatient type 2 diabetics.
Target blood sugars…
No hypoglycemic episodes
Pre-meal: less than 140 mg/dl
Random: less than 180 mg/dl
Which type of premeal insulin is preferred in gastroparesis patients and why?
Regular insulin, which is short acting instead of rapid acting, because patients with gastroparesis empty out their stomach slower and glucose takes longer to be absorbed and reach the blood stream.
Duration of action of regular insulin is 4 - 8 hours.
Types of basal insulin.
Lantus/glargine - 24 hours action.
Levemir/detemir - 12 to 24 hours action.
NPH (intermediate-acting) - always dose twice a day. Sometimes type 1 diabetics do better with NPH.
Insulin dosing based on fasting blood sugars, weight, age and renal function.
Fasting Blood Sugar 140 - 200 mg/dl, then 0.4 units/kg body weight.
Fasting Blood Sugar 201 - 400 mg/dl, then 0.5 units/kg body weight.
If age more than 70 years or GFR less than 60 ml/min, then 0.2 - 0.3 units/kg.
Give half of the calculated dose as basal and the other half in divided doses as pre-meal.
A diabetic patient on steroids has high blood sugars.
Would you increase the basal or pre-meal insulin?
Typically the pre-meal insulin needs to be increased.
A diabetic patient is on an insulin drip in the ICU for blood sugar control.
What range should the blood sugars be maintained at?
Between 140 - 180 mg/dl.
What adjustments should you make to the insulin regimen when a patient has overnight and morning hypoglycemia?
Always go and assess the patient.
Decrease the basal insulin by 25 - 50%.
After hypoglycemic episode patient is at risk for further episodes until it is time for the next dose of long acting insulin, so blood sugar so be checked every 2 hours for the next 24 hours.
How long does it take for Dilantin/Phenytoin to reach steady state in the blood stream when given as oral medication?
7 days
How do you treat phlebitis from a peripheral intravenous line?
Warm compresses.
It can give you fevers.
Sometimes vancomycin and clindamycin are used together in infections such as cellulitis.
Why?
Vancomycin and penicillins act on the cell wall and are bacteri-cidal. When the bacteria die then they release toxins that can increase the erythema and make the infection appear worse. Clindamycin is bacteri-static and prevents this effect.
It is called the Eagle effect.
What is the most likely cause of nephrotic syndrome in a patient with a history of cancer?
Membranous glomerulonephritis.
Cancer is associated with membranous glomerulonephritis. If a patient with a history of cancer develops nephrotic syndrome then this may indicate reactivation of the cancer.
Diabetes Mellitus type 2
Does surgery have a role?
New research indicates that bariatric surgery coupled with optimal medical management provides better glycemic control than optimal medical management for type 2 diabetics alone.
The mean BMI was 37 and these patients had already failed medical therapy. Unclear whether surgical benefits extends to patients who are not as overweight.
Which formula estimates GFR more accurately?
CKD-EPI or MDRD?
(And what do they stand for?)
The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation more accurately estimates GFR, and more accurately categorizes the risk for mortality and ESRD when compared with the MDRD (Modification of Diet in Renal Disease) study equation.
What’s the diagnosis?
Hypersexuality Neurological changes and behavioral changes Hypermethamorphosis Hyperphagia Memory changes
Kluver-Bucy Syndrome
What drug would you add in addition to Vancomycin in a patient with infected hardware?
Rifampin.
In cases of infected hardware where there is a layer of slime over the bone, Rifampin increases the penetration of Vancomycin to the bone, treating osteomyelitis better.
What is the treatment of Helicobacter Pylori?
Triple therapy: PPI (twice a day), amoxicillin 1 g b.i.d. and clarithromycin 500 mg b.i.d for 10 - 14 days. If penicillin allergic then instead of amoxicillin give metronidazole 500 mg b.i.d.
Quadruple therapy: PPI (twice a day), bismuth 525 mg q.i.d. and two antibiotics, metronidazole 250 mg q.i.d. and tetracycline 500 mg q.i.d. for 10 - 14 days.
