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Examine Complex Patient 6671 > Week7 6671/6611 > Flashcards

Week7 6671/6611 Flashcards

1
Q

SBO- small bowel obstruction

Causes (common)

A

Adhesions
Hernias
Inflammatory diseases
Tumors

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2
Q

SBO - small bowel obstruction

S/S

A 
Cramping and abdominal pain (5-15 min waves; centered on navel or between navel and rib cage) 
Nausea and vomiting 
No gas passing through the rectum 
Abdominal bloating
Rapid pulse and rapid breathing 
Upper epigastric distention 
Constipation 
Lack of appetite
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3
Q

LBO- large bowel obstruction

Common causes

A

Colorectal cancer
Volvolus
Diverticular disease

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4
Q

In general obstruction of small intestine presents with ____, as ____ tends to be more large bowel obstruction.

A

Colicky abdominal pain and vomiting (SBO)

Distention and absolute constipation tend to be more common in large bowel obstruction

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5
Q

LBO- large bowel obstruction

S/S

A 
Lower abdominal bloating/distention 
Lower abdominal cramping and pain 
Constipation
Diarrhea 
Possible rectal bleeding
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6
Q

80% of bowel obstruction are ___

A

Large intestines (LBO)

In developed countries- usually from adhesions.

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7
Q

Volvolus

A

Twisting of bowel around itself
(LBO)

Most common >65 y/o w/ hx of chronic constipation

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8
Q

Red flags for immediate medical referral

A

Intense and/or constant abdominal pain

Vomiting

Bloating

Blood in the stool

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9
Q

GI system checklist

A

Swallowing difficulties
Indigestion/heartburn
Food intolerance
Nausea/Vomiting

Bowel dysfunction: 
Color of stool
Shape, caliber of stool
Diarrhea 
Difficulty initiating 
Incontinence
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10
Q

Causes of dysphagia

A 
Muscle incoordination:
Myasthenia gravis 
MS 
Amytrophic lateral sclerosis 
Parkinson’s 
Mechanical obstruction: 
Tumors
Thyroid goiter 
Osteophytes of c-spine
Aortic aneurysm
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11
Q

Clinical manifestations of dysphagia- motor cause

A

Onset: gradual
Progression: slow
Equal difficulty w/ soft foods vs liquids
Worse swallowing cold substances
Bolus passage: repeated swallowing; valsalva maneuver, throwing back head and shoulders

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12
Q

Clinical manifestations of dysphagia- Mechanical cause

A

Onset: faster
Progression: faster
More difficulty swallowing solids than liquids
Swallowing difficulty not affected by temperature
Bolus passage: can be accompanied by regurgitation

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13
Q

Questions to ask about dyspepsia (indigestion/heartburn)

A

How long have you had symptoms?
Do you know what is causing?
Constant or intermittent?
How are you treating the symptoms?

Associated symptoms:
Fatigue
Weakness
SOB

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14
Q

Common food intolerances

A 
Cheese
Chocolate 
Citrus 
Nuts 
Red wine

Can be warning sign for underlying pathology - ie gallbladder

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15
Q

Melena (GI bleeding- dark)

Questions to ask

A

How long have you been having black, tarry stools?
Have you felt lightheaded?
Have you had any nausea, vomiting, diarrhea, fatigue, abdominal or back pain, or sweats associated with these stools?

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16
Q

Obstructive jaundice

Questions to ask

A

How long have you noticed the light, pale-colored stools?
Have you noticed an atypical color (ie dark) of urine?
Have you noticed any associated symptoms such as fatigue, fever, chills, unexplained weight changes or nausea?

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17
Q

Hematochezia (red blood stools) questions to ask

A

How long have you noticed bright red blood in your stool?
Is the red blood mixed within the stools (red streaks) or not?
Are there any associated symptoms, such as difficulty in initiating bowel movements or feeling of lightheadedness or fatigue?

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18
Q

“Have you noticed any unusual shape of your stool recently, such as pencil-like in diameter, flat and ribbon-like?”

Question is asking about?

A

Colon carcinoma

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19
Q

Potential causes of constipation

A 
Impaired mobility 
Inadequate dietary fiber 
Inactivity 
Diverticulitis 
Hypothyroidism 
Hypercalcemia 
Scleroderma 
Neurologic dysfunction 
MS
SCI 
Psychosocial dysfunction 
Depression/Anxiety 
Situational stress
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20
Q

Potential causes- diarrhea

A 
Infectious agents 
Laxative abuse 
Colon cancer 
Irritable bowel syndrome 
Crohn’s 
Ulcerative colitis 
Diabetic enteropathy
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21
Q

Diarrhea questions to ask

A

How many episodes each day?
How long gave you gas diarrhea?
Do you ever have periods of diarrhea alternating with periods of constipation?
Is diarrhea worse at certain times of day?
Do family members or companions have similar symptoms?
Do you have any associated symptoms such as fever, chills, nausea, vomiting, confusion or abdominal pain or distention?

22
Q

S/S of dehydration

A 
Thirst and dry mouth 
Postural hypotension 
Rapid breathing 
Rapid pulse (>100 bpm) 
Confusion, irritability, lethargy 
HA
23
Q

Hematuria

And questions to ask

A

Blood in urine

How long have you noticed red urine?
Do you have a hx of bleeding problems?
What medications are you currently taking?
Do you currently have, or have you recently recovered from an upper respiratory infection or sore throat?

24
Q

ED can be associated with

A 
SCI
Herniated disk 
Post surgical complications: radical prostate, bladder, colon procedures 
DM
Medication side effects 
Psychogenic disorders
25
Q

Causes of bowel obstruction

A

Mechanical:
Adhesions
Hernias
Tumors

Other: 
Diverticulitis 
Foreign bodies 
Intussusception
Fecal impaction

Also consider: Ogilvie syndrome; Post-op ileus

26
Q

About __% of partial bowel obstructions resolve without operative tx

About __% of complete bowel obstructions require surgery

A

85%

85%

27
Q

Suspicion of bowel obstruction requires?

A

Hospitalization

28
Q

Bowel resection

A

AKA partial colectomy

Can be open or laparoscopic

Obstruction, Cancer, Crohn’s, diverticulitis, severe bleeding

Sometimes colostomy needed

29
Q

Colostomy

A

Surgical procedure bringing portion of the large intestine through the abdominal wall to allow passage of bowel material out of the body as an alternative to the anus

30
Q

Reasons for colostomy

A

Treat various large intestine disorder (cancer, obstruction, IBS, ruptured diverticulum, ischemia)

Can be temp to divert stool from injured/diseased section of large intestine

Can be permanent when distal bowel removed or blocked or inoperable (ie colorectal ca)

31
Q

3 types of colostomy

A
  1. End colostomy- usually permanent
  2. Double barrel colostomy- usually temp
  3. Loop colostomy- usually temp
32
Q

Stoma

A

External opening of the colostomy
Made by bringing end of intestine through an opening in abdomen and attaching it to the skin

Serves as connection for removable external collection pouch (ostomy appliance)

33
Q

Colostomy post-op care

A

NG tube w/ low to intermittent suction until bowel activity returns

Stoma monitored w/in 72 hrs passage of stool begins
Diet (advanced as stoma becomes active)

Psychological consult

ERAS

D/C home 2-4 days depending on pain and GI activity; Possible return in 3-6 mo for colostomy “take down”

34
Q

PT implications- post-colostomy

A

Activity restrictions:
No driving, heavy lifting 2-3 weeks
Avoid extreme physical exercise and sports for 3 mo
Eventually no activity restrictions, except maybe contact sports

Swimming is fine and encouraged.

35
Q

BMI

A

< 18.5 underweight
18.5-24.9 normal weight
25-29.9 overweight

30-34.9 obese-1
35-39.9 obese-2
40 and < morbidly obese

36
Q

Waist circumference

Obesity

A

Men > 40”
Women > 35”

Increased risk of heart disease and DM2

37
Q

Bariatric

A

Branch of medicine that deals with causes, prevention and tx of obesity

38
Q

Clinical manifestations of obesity: Increased risk of…

A 
CV disease 
DM 
Stroke 
Arthritis 
Gallbladder disease 
Respiratory conditions 
Cancers
39
Q

Metabolic syndrome

A

Group of conditions that lead to development of CV disease and DM2

Primary risk factors:
Abdominal (central obesity)
Insulin resistance

40
Q

Metabolic syndrome - Dx

A

Dx with 3/5 conditions met
1. Waist circumference M > 40” F>35”

  1. Fasting glucose 100 mg/dL or use of meds for hyperglycemia
  2. Triglycerides > or = 150 mg/dL
  3. BP > or = 130/85 or use of HTN meds
  4. HDL M<40 mg/dL F<50 mg/dL
41
Q

Wight distribution

A

Apple:
Apple pannus- inferior abdominal drift of adipose
Apple ascites- large abdomen, don’t tolerate lying flat

Pear: (Mostly in F)
Pear ABD- more weight hips/butt downward, tends to have knee valgus
Pear ADD- tends to have knee varus
Gluteal shelf- large gluteal mass of adipose

42
Q

Mobilizing obese

A

Transfer sheets, overhead grab bar or trapeze, bariatric gait belts, other bariatric equipment

Spend more time planning than doing
Include pt in decision making

Number of people needed - consider 2-3 at most

43
Q

Normal/Standard medical equipment is usually rated for about ____.
Bariatric equipment for ___.

A

250-300 lb max

Bariatric equipment rates for over 300 lbs

44
Q

Mobilizing/Positioning -

Apple ascites obese

A

Little tolerance for supine or prone
Positioning

Supine -> Sit: flat spin with a sheet

45
Q

Mobilizing/Positioning -

Apple pannus obese

A

Variability with supine tolerance

Supine -> Sit: Flat spine w/ sheet or prone flat spin w/ UE push up to stand

46
Q

Mobilizing/Positioning -

Pear obese

A

Supine -> Sit: via long sitting to raise head of bed and use sheet to assist to EOB

47
Q

Gait belt grips - obese

A

Thumb grip:
Face pt, cross arms, hand under belt from top palm out, bring 2 fingers to thumb,
Control slack w wrist flexion, radial deviation, elbow flexion

Twist grip:
Pt side, hand down into belt palm to back, twist toward thumb, control slack w wrist flexion, radial deviation, elbow flexion

48
Q

Egress test

Sage to ambulate w/ bariatric pt

A
  1. Ask pt to lift bottom off surface as if going to stand (1-2 inch clearance) then return to sitting
  2. Ask pt to come all the way up to standing and bear weight on both LE 2x
  3. Ask pt to perform 3 reps of March in place
  4. Ask pt to take 1 step forward and then return to start position. Do this bilaterally.
49
Q

Bariatric- exercise rx

Goals

A

Pt centered- behavior modification (not always weight related)

Weight loss 10% at 1-2 lbs a week

Increase physical activity to reduce risk of obesity related disease- aim for up to 1 hour moderate intensity 5x/week

50
Q

Abdominal pain of MSK origin question clusters

A

cluster 1:

  1. Does coughing, sneezing, or taking a deep breath make your pain feel worse? (Yes)
  2. Do activities such as bending, sitting, twisting, lifting, or turning over in bed make you pain feel worse? (Yes)
  3. Has there been a change in your bowel habit since the start of your symptoms? (No)

Answering “yes” either to Q1 or Q2, and “no” to Q3 = moderate probability is MSK in origin

Cluster 2:

  1. Does eating certain foods make your pain feel worse? (No)
  2. Has your weight changed since your symptoms started? (No)

The probability increases to strong if both “no”

51
Q

Abdominal pain of MSK origin may present as

A

Sharp and focal, cramping and aching, or deep.

In comparison, pain from visceral is often dull, aching, cramping, burning, gnawing, wave-like and poorly localized

Both can present with nausea

Examine Complex Patient 6671 (8 decks)

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