Test 1 Flashcards
Gastroenteritis
Assess: History of illness, physical exam
- duration of symptoms, blood in stool? Cdiff sample or stool culture
- check electrolytes
GERD
Assessment: patients often complain of sour taste in mouth, rule out cardiac problems
-educate on aggravating factors
- if treatment ineffective, may need endoscopy with biopsy
- watch for Barrett esophagus which is precursor to cancer
- h.pylori is not helpful in dx or tx
Appendicitis Signs
1) rebound tenderness
2) heal tap
3) psoas
4) obturator
5) rovsings
6) cutaneous hyperesthesia
heal tap
raise heal 10-20% and hit the heal firmly with the palm of the hand
psoas sign
place hand above the patients right knee and have them raise it
Obturator Sign
flex the patients right thigh at the hip, with the knee bent, and rotate the leg internal at the hip
rovsing sign
pain in the RLQ during left sided pressure
cutaneous hyperesthesia
pick up folds of the skin on the abdominal wall
sign of cholecystitis
Murphy sign = take a deep breath; pain when pressing in RUQ
Appendicitis
-Most common 5-50 years old
Tests
- elevated WBC (>20,000 = perforation)
- UA - hematuria and pyuria
- Pregnancy test and US (rule out ectopic pregnancy)
- CT scan ***
Cholecystitis
GALLSTONES
lab tests
- WBC elevated (12-20,000)
- Alk.Phos, AST, ALT, bilirubin elevated
- GGT can be elevated if bile duct obstructed
imaging
- US (most sensitive and specific)
- HIDA scan
- ERCP
Crohn’s Disease
15-25 years old
DX = colonoscopy with biopsy
-mostly small intestine but can occur anywhere
labs
- Antiglycan antibody - elevated in 75%
- sed rates and c-reactive proteins elevated due to inflammation
- CBC for anemia
IMAGING
Barium X-rays and enema
Ulcerative Colitis
15-40 years old
DX = colonoscopy or sigmoidoscopy with biopsy
-mostly in large intestine and rectum
tests
- pANCA antibodies elevated in 85%
- barium enema
- CBC for anemia
Diverticulitis
assess = abdominal, pelvis, and rectal exam
- most common exam = ABDOMINAL CT
- Colonoscopy is not necessary with uncomplicated diverticulitis, but may do 4-6 weeks after resolution
- may check: CBC (anemia), WBC (infection), and CMP (electrolytes)
Pancreatitis
Send to ER quickly
Diagnostics (2 of 3)
1) abdominal pain
2) CT scan
3) serum lipase and amylase (greater than 3x normal, but etoh pt may not produce these enzymes anymore)
Pyloric Stenosis
onset from 3-4 weeks to 5 months old
baby who is dehydrated from projectile vomiting
-obtain ultrasound and upper GI series (thin elongated pyloric canal, called “string sign”)
Hirschsprung’s Disease
dilated bowels causing lack of motility in those areas
obtain:
- cbc
- abdominal xrays (dilated loops of bowel)
- biopsy (absence of ganglion cells)
Intussusception
Bowel goes into itself- “jelly stools”
GOLD STANDARD: barium enema (will see “coiled springs”, may reduce the intussception
- abdominal xray (rule out perforation before obtaining a barium enema)
- stool occult blood
Patient presents with HIGH TSH, and LOW T3, T4 levels- the patient has….
Hypothyroid
Patient presents with LOW TSH, and HIGH T3, T4 levels- the patient has….
Hyperthyroid
Hypothyroid Symptoms
- Fatigue
- Dry skin, hair loss, brittle nails
- cold intolerant
- weight gain
- memory loss
- delayed deep tendon reflex
- edema
- depression
- bradycardia
Hyperthyroid Symptoms
- Nervousness
- exopthalmos (protruding eyes)
- heat intolerant, sweaty
- weight loss
- tachycardia
- tremors
- accelerated growth in children
Testing for thyroid
Hypothyroid = test every 6-8 weeks until normal. Check TSH, T3, T4
Hyperthyroid = Check TSH and T4, check CBC and liver function. Assess growth and development in children
Type 1 DM
DX ages 8-12 but can occur 30’s and 40’s
polydipsia, polyphasic, polyuria
Type 2 DM
DX adults but increases to all ages
3 P’s, chronic skin infections, vision changes, and yeast infections in women
A1C
diabetes = > or equal to 6.5%
prediabetes = 5.7-6.4%
Diabetes Diagnosis- Fasting plasma glucose levels
Diabetes = > or equal to 126
Prediabetes = 100-125
2hr oral glucose tolerance testing (OGTT)
diabetes = > or equal to 200
prediabetes = 140-199
random glucose
diabetes = > 200
screening for diabetes
begin at age 45 and performed every 3 years.
fasting plasma glucose (FPG) is recommended as the screening test
Adrenal Insufficiency or Addison’s
Most often autoimmune, but can occur after DC long term steroid treatment
average 30-50 years
SX: fatigue, weak, cold intolerant, hypotension
Labs: low sodium, high potassium, low glucose
DX: ACTH. morning cortisol <165 = adrenal insufficiency
Cushing’s
Too much glucocorticoid from excess production of ACTH
SX: truncal obesity, buffalo hump, amenorrhea, moon face, hypertension
Late night salivary cortisol or 24hr free urinary free cortisol (elevated = positive)
Two types of decision making
1) pattern recognition
2) probabilistic
Thresholds of Probability
1) Test Threshold - when probability of the disease is low, you do not treat or test
2) Treatment Threshold - when probability of disease is high, you treat empirically
3) Diagnostic Tests - when probability of disease is in the middle between the two, further testing needs to occur, send more tests
Sensitivity
SNOUT
negative test result rules out having the disease- fewer false negatives.
correctly identifies people who have the disease
true positive
90% sensitivity test - 90% of those who are tested are positively identified, and 10% have negative test but are actually positive
Specificity
SPIN
positive test results rules in having the disease, fewer false positives
correctly identifies people who do not have the disease
true negative
90% specificity test - 90% of those who are tested and test negative are correctly identified, 10% chance of false positive
screening test
ID a disease in a healthy person
diagnosis testing
testing for a diagnosis in someone with symptoms
CLIA
Clinical Laboratory Improvement Amendments
Tests that are waived under CLIA
UA - dipstick Urine - pregnancy Blood Glucose Monitor Hemoglobin Blood Count Blood Chemistry
PPM
Provider-performed microscopy procedures
Examples of PPMs
Wet mounts KOH preparations Pinworm examinations FERN tests UA Semen Analysis
When should Pap smears begin?
21 years old
Womens Health routine exams- what data should be collected
- ht, wt, bmi
- vs, blood pressure (every 1-2 years)
When should colonoscopy’s begin
50 years unless family history
45 years (ACS)
rectal exam for occult blood
when to get Dexa Scan?
under 65 years for postmenopausal women with risk factors
over 65 years and older as needed
how often should cholesterol be tested
every 4-6 years in adulthood (>21)
how often should blood glucose be tested
peds: over age 10 if family hx DM2
adults:
18-44 if overweight and RF
45 if overweight
how often should test for STI
1) if sexually active
2) 24 years old
How often should Pap smears be performed?
21-29: every 3 years
30-65: every 3 years with HPV testing every 5 years
after 65 can stop if no abnormal paps in history and 3 negative HPV co-testing
How often should Clinical Breast exams occur
annually for women age 19 and older
Mammograms and how often for screening
Start: age 40 and every 1-2 years
screening until at least 75
family history and risk factors can start 10 years earlier
Pregnancy tests
Urine Qualitative: highly sensitive at 10 days post-conception
Serum Qualitative hCG: positive or negative. if positive, continues to rise in first trimester
Serum QUANtitative hCG: continues to rise through first trimester. Testing levels can help with diagnosis of miscarriage
KOH Prep
10% potassium hydroxide
“whiff” test: fishy odor indicates BV
after 5 mins: examine for yeast, KOH will kill every other element except yeast because its fungal
RBCs on Wet Prep
typically not seen unless bleeding
round with donut depression
WBCs on Wet Prep
Very few should be seen
present in infectious or inflammatory disorder
lots of WBCs- suspicious for chlamydia or gonorhhea
pH of vagina
<4.5, very acidic
lactobacilli are normal
Vaginitis differentiation: BV
presentation: odor, discharge, itchy
discharge: thin, milky white, foul fishy smell
pH: >4.5,
KOH whiff: positive
Wet Mount: Clue cell (scrambled eggs with pepper), few WBC
Vaginitis differentiation: Yeast
presentation: itchy, dysuria, discomfort, thick discharge
discharge: “cottage cheese”
clinical findings: inflammed and swollen
vaginal pH: <4.5
wet mount: few WBCs, pseudohyphae and yeast buds
Vaginitis differentiation: Trichomoniasis
presentation: itch, discharge, 50% asymptomatic
vaginal discharge: frothy, grey-green, malodorous
clinical findings: strawberry red cervix with petechiae
pH: > 4.5
whiff test: often positive
wet mount: motile flagellated (pulsate) protozoa, many WBCs
there is point of care testing for trichomoniasis but expensive
BPH
symptoms: frequency, urgency, dribbling, nocturne, retention
firm, smooth, symmetrical enlarged prostate
diagnosis:
BPH self-administer tool for BPH diagnosis, DRE, PSA, urinalysis, US
Prostate Cancer
most common after age 60
ASSESSMENT: may be asymptomatic, prostate feels hard (nodules) upon DRE, pt may be anemic
diagnosis:
-DRE, prostate ultrasound, PSA can be normal or elevate (>10 refer to urologist)
African American and family history are RF
Acute Prostatitis
incidence = 30-50 year old, very sexually active
Assessment= high suspicion for STD’s- abrupt onset- fevers, chills, malaise, enlarged tender prostate and pain on urination, ejaculation, and defication
Diagnosis = STI testing -culture and sensitivity of expressed prostate secretions,
UA (WBC present), fractional urine exam, urine culture
**don’t check PSA because will be elevated from infection, so wait 4 weeks after treated
Chronic Prostatitis
Incidence = after 50 years old
Assessment = asymptomatic or mild tenderness with enlargement. Dysuria, hematuria
Diagnosis = same as acute, test expressed prostate secretions and urine for culture and sensitivity
UA (WBC, RBCs), fractional urine exam
CT TO CONSIDER FOR CANCER
Cryptorchidism
Common in premature infants
Assessment = absence of one or both testes on palpation (assess not laying down)
Diagnosis = Ultrasound to identify the location and presence of testes
- refer to urologist if they haven’t descended by 4 months
- increased lifelong consequence of testicular cancer (20-60% risk)
Epididymitis
Incidence = <35 years old, sexually active
Assessment = very tender epididymis (posterior testes), and enlarged and hardened (induration).
-Decreased pain when testes are lifted/elevated
Diagnostics = Look for STI’s (Urine, urethral, discharge culture and testing for gonorrhea and chlamydia), Syphilis serology, HIV screen
Doppler US of scrotum, UA
Testicular Torsion
Incidence = peak at age 14, puberty
Assessment = sudden, severe UNILATERAL pain. Scrotal edema and mass that appears to retracted up. Absent cremasteric reflex. Nausea, vomiting, lower abdominal pain
Diagnostics = send immediately to ER, emergency and doppler ultrasound needed
Hydocele
Collection of peritoneal fluid in scrotum in infants.
painless, large scrotum - resolves on own
Diagnose = scrotal US
Spermatocele
Mass in scrotum along spermatic cord containing sperm.
Assess: freely moveable and painless, easily transilluminated
Diagnosis = scrotal US, urologist if bothersome
Varicocele
Collection of abnormally large dilated veins in scrotum (“bag of worms”) in older adolescents
Assess = Often Left scrotum that resembles a bag of worms (if occurs in right could be a cancer risk)
Diagnosis - doppler US, sperm count (infertility issues)
Testicular Cancer
Incidence 15-35 years old
Assess = solid firm, contender testicular mass, sensation of heaviness and fullness in scrotum. MASS DOES NOT TRANSILLUMINATE
Diagnosis = Gold standard (SCROTAL US), test tumor markers, refer to urologist
Abdominal and chest CT for metastasis, biopsy
Inguinal Hernia
80% of hernias
indirect - 3-5% kids. more common
direct = adults
assessment = heaviness in group, scrotum increases with size when standing or straining - strangulated hernia is a medical emergency
DX = US, refer to surgeon
Erectile Dysfunction
Higher incidence in men who are being treated for hypertension
if the patient is young, you want to investigate further
Diagnose = CBC, Hormone levels, fasting blood sugar, TSH, digital rectal exam
refer to urologist, surgeon, neurologist etc
