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74 Cards in this Set
- Front
- Back
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Differential diagnosis: ABDOMINAL PAIN WITH FEVER
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APPENDICITIS
PERITONITIS PANCREATITIS GASTROENTERITIS PELVIC INFLAMMATORY DISEASE |
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Differential diagnosis: ABDOMINAL PAIN WITHOUT FEVER
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SMALL BOWEL OBSTRUCTION
BOWEL MASS GERD GASTRITIS CONSTIPATION |
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Differential diagnosis: ABDOMINAL PAIN WITH JAUNDICE
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Cholelithiasis
Acute Pancreatitis Infectious Mononucleosis Cirrhosis Hepatitis Biliary duct obstruction |
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Colon Cancer Screenings STANDARD
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STARTING AT AGE 50
FOBT-ANNUAL OR SIGMOIDOSCOPY- EVERY 5 YEARS OR COLONSCOPY- EVERY 10 YEARS |
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Colon Cancer Screenings- Low familiar risk for sporadic cancer
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STARTING AT AGE 40
FOBT- ANNUAL OR SIGMOIDOSCOPY-EVERY 5 YEARS OR COLONSCOPY- EVERY 10 YEARS |
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Colon Cancer Screenings- High familiar risk for sporadic cancer
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STARTING AT AGE 40
COLONOSCOPY EVERY 5 YEARS |
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DIVERTICULITIS: PRIMARY PREVENTION
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High fiber diet
Fiber supplements Exercise (speculative – increases motility) |
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DIVERTICULITIS: SECONDARY PREVENTION
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NONE!
Though not recommended specifically for this disease, colonoscopy screening as per colon cancer would identify diverticular disease early |
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DIVERTICULITIS: MANAGEMENT: UNCOMPLICATED
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No toxicity, peritoneal signs, may have pain, tenderness and leukocytosis
Clear liquid diet Advance diet once well (3-10 days), as tolerated, eventually to high fiber diet with adequate fluid intake No scientific data support avoidance of nuts, popcorn and seeds Activity as tolerated Antispasmotics Levsin 0.125 mg q 4 h Analgesics as indicated for pain control Antibiotics tx for 10 days Ciprofloxicin 750mg BID (or Bactrim) x 10day and Flagyl 500mg QID |
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DIVERTICULITIS: MANAGEMENT: COMPLICATED
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2% pts require hospitalization for toxicity, septicemia, peritonitis, failure to resolve
Half of these pts require surgery (perforation, abscess, fistula, severe bleeding >2L/d) IV fluids if severe IV antibiotics: Ampicillin-sulbactam (Unasyn) 3 g IV q6hours Piperacillin (Zosyn) 4.5g IV q8h Analgesics NG tube May require surgery: partial colectomy- if chronic and debilitating: laparoscopic procedure only possible if stable |
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DIVERTICULITIS: DIAGNOSIS: LABS
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WBC elevated
Hg low if bleeding ESR elevated U/A, WBC, RBC, Urine culture: persistent infection if fistula Blood culture: pos with generalized peritonitis |
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DIVERTICULITIS: DIAGNOSIS: DIAGNOSTIC TESTS: WHAT is the priority
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CT for peritonitis, abscess, fistula, size and location inflammation – and establishes diagnosis
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ABD PAIN: DIAGNOSTICS: Diagnostic Radiography: As per diagnosis
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Angiography (or spiral CT c contrast): diverticular bleeding
Fistulograms if needed |
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ABD PAIN: DIAGNOSTICS: Not priority or potentially harmful
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Colonoscopy needed to exclude cancer – but not done emergently with acute abdomen
Plain abd films are not useful in peritonitis or perforation, but can show free air if acute abdomen Contrast enema: best with diverticulosis, not for diverticultis, and contraindicated with acute diverticuli Use water soluble contrast if any concern about perforation |
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PUD: PRIMARY PREVENTION
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Avoid/decrease use NSAIDs
Quit cigarette smoking Associated with corticosteroid use – minimize overuse if possible Stress reduction (questionable if effective) May not be related to etoh, caffeine, dietary spices, Tylenol If anything irritates stomach, best to avoid but … bland diet DOES NOT promote healing! |
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Primary prevention if caused by NSAIDs
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Non NSAID analgestics (e.g. Acetaminophen)- 500-1000 mg PO q 6 hours as needed (MAX 4 gms/DAILY)
MISOPROSTOL- 200 mcg PO TID-QID PPIs Esomeprazole 20-40 mg PO DAILY Lansoprazole 15 mg PO DAILY Omeprazole 20 mg PO DAILY Pantoprazole 20-40 mg PO DAILY Rabeprazole 20 mg PO DAILY CELECOXIB- lowest possible dose (max 400 mg/day for most indications) |
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Secondary Prevention: PUD
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NONE!
Early diagnosis facilitated by high level of suspicion in: 1. pts taking NSAIDs to facilitate early diagnosis 2. H pylori levels in symptomatic pts (some resources suggest only doing in face of positive ulcer finding e.g. positive fecal blood) 3. Fecal blood – requires follow-up studies to determine site of bleed NB: Hg may be normal unless hemorrhage |
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PUD: ASSESSMENT: IMAGING
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Endoscopy more accurate than radiology, and Endoscopy is considered less expensive
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PUD: ASSESSMENT: LABS
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H. pylori (Peters, 2010)
Serum antibody – cheapest non-invasive test-remains positive for years after eradication Only useful if negative as a positive needs to be confirmed with one of other two tests Stool antigen – highest sensitivity and specificity – can test for resolution Carbon-labeled urea breath testing – most accurate non-invasive test and resolution Accurate 4 weeks after treatment for eradication Fecal occult blood Would you draw a Hg? Consider serum gastrin (seen in Zollinger-Ellison syndrome) |
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H Pylori Serum Antibody
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cheapest non-invasive test-remains positive for years
after eradication Only useful if negative as a positive needs to be confirmed with one of other two tests |
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What h pylori test has the highest sensitivity and specificity?
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Stool antigen – highest sensitivity and specificity – can test for resolution
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most accurate non-invasive test and resolution for h pylori
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Carbon-labeled urea breath testing – most accurate non-invasive test and resolution
Accurate 4 weeks after treatment for eradication |
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PUD: Management: Guidelines
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In young, healthy, person with dyspepsia and without weight loss, or persistent vomiting; AND <45 years (American College Gastroenterology, 2010; Chey, 2007)
Empiric treatment initially is considered reasonable All others: Endoscopy Emergency endoscopy and hospitalization if suspected ulcer bleeding |
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IF NEGATIVE FOR H pylori treat: RULE OF THUMB
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just with acid suppression:
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If negative for H PYLORI how long do you treat a gastric ulcer
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12 weeks
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If negative for H PYLORI how long do you treat a duodenal ulcer
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8 weeks
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PUD therapy: H2 receptor antagonists (H2RA)
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No longer considered first line, but much cheaper and otc when compared to PPIs
Examples: Ranitidine or Nizatidine 150 bid or 300 mg HS Cimetidine 400 bid or 800 HS (very inexpensive) |
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PUD Therapy: Proton pump inhibitor
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Treat for 4 – 8 weeks e.g.
First line drug choice usually Promote healing of ulcer Examples: Omeprazole 20 mg qd (may be curative of PUD in 8 weeks) |
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What is the first line treatment for PUD?
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PPI
treat for 4-8 weeks (may be curative in 8 weeks) promotes healing of ulcer |
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H pylori eradication protocols
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Multiple “triple therapy” regimen
Example for two weeks (first line treatment 2013) Omeprazole 20 mg bid Clarithromycin 500 bid Amoxicillin 1 gm bid |
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GERD: Primary Prevention
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Avoid smoke, ETOH, and caffeine – coffee
Weight management Avoid meds that lower esophageal sphincter tone: Theophylline, anticholinergics, progesterone, calcium channel blockers, alpha adrenergic agents, diazepam, meperidine Avoid foods that lower esophageal sphincter tone: High-fat foods, yellow onions, chocolate, peppermint Avoid foods that irritate esophagus: Citric fruits and juices, spicy food and drinks |
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GERD: SECONDARY PREVENTION
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NONE!
Testing for H pylori in high risk population is controversial. Use if no improvement with treatments – then is diagnostic NOT screener. |
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GERD: Tertiary prevention
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Step therapy:
Elevate HOB, avoid laying supine after meals, avoid valsalva maneuver, low fat diet, smaller more freq meals Wt loss if needed OTC antacids or H2 antagonists Stool antigen test for H pylori eradication following treatment Vitamin B 12 levels in patients with atrophic gastritis Hct |
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GERD: ASSESSMENT: DIAGNOSTICS
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Consider
Barium swallow (finds ulcers and strictures, but not mucosal injury) – INSENSITIVE TO GASTRITIS Useful if patient also has dysphagia Esophagoscopy with biopsy ( preferred choice for outcome, cost, finding of Barrett’s esophagus, and pt preference) Esophageal pH monitoring and/or gastric analysis (use if atypical GERD) Esophageal manometry if surgery considered |
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What is the preferred choice for GERD DIAGNOSTICS?
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Esophagoscopy with biopsy ( preferred choice for outcome, cost, finding of Barrett’s esophagus, and pt preference)
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GERD: Management and Interventions
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Step therapy includes dietary/lifestyle changes listed earlier for all individuals
Step treatment Mild symptoms: OTC H2 receptor antagonists (H2RA), antacids American Gastroenterology Assn most recent guidelines at guidelines.gov (2008): “Antisecretory drugs for the treatment of patients with esophageal GERD syndromes (healing esophagitis and symptomatic relief). In these uses, proton pump inhibitors (PPIs) are more effective than histamine2 receptor antagonists (H2RAs). ….Twice-daily PPI therapy for patients with an esophageal syndrome with an inadequate symptom response to once-daily PPI therapy.” Moderate - severe symptoms: proton pump inhibitors (PPIs) or prescription strength H2RAs Ulcerated esophagus: surgery H2RAs: Cimetidine (Tagamet) 800mg bid is least expensive option Many patients may have tried this otc already Heartburn history has a positive predictive value >80% warranting empiric initial care in absence of worrisome symptoms Empiric trial of proton pump inhibitor compares well to pH monitoring as diagnostic tool for GERD NB: Complications more likely in elderly |
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Cholecystitis: Symptomatology
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Intermittent pain, typically RUQ immediately following classically a meal of high fats
Pain is intense with radiation to epigastrum, R shoulder or back Classic ‘biliary colic’ is pain rising over 2-3 minutes to plateau of intensity maintained for >20 minutes Any suspicion that pain origin is cardiac warrants an emergent referral for cardiac workup Usual symptoms Anorexia, Abd bloating, Belching Nausea , Vomiting |
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Cholecystitis: acute presentation
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Acute presentation – emergent surgical referral:
May appear acutely ill Temp may be mildly to moderately elevated Abdominal distension Local epigastric/RUQ tenderness – rarely diffuse Jaundice Loose, light-colored stools Physical assessment special tests: Inspiratory arrest when palpating RUQ and pt taking deep inspiration (also with tenderness) Ortner’s sign: tenderness when hand taps the R edge of costal arch. Georgievskiy - Myussi's sign (phrenic nerve sign) - pain when press between edges of sternocleidomastoid muscle Boas' sign – Tenderness inferior to R scapula (also can be seen with phrenic nerve irritation) |
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Murphy's sign
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Inspiratory arrest when palpating RUQ and pt taking deep inspiration (also with tenderness)
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Ortner’s sign
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tenderness when hand taps the R edge of costal arch.
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Georgievskiy - Myussi's sign
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(phrenic nerve sign) - pain when press between edges of sternocleidomastoid muscle
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Boas' sign
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Tenderness inferior to R scapula (also can be seen with phrenic nerve irritation)
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Cholecystitis: Symptomatology and assessment - chronic
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Chronic presentation –
Usually only pain and nausea as with acute presentation, other symptoms absent Consider laparoscopic cholecystectomy as outcomes poorer if acute presentation for surgery (Ferri, 2007) Consider referral to gastroenterologist for dissolution agent, shock-wave lithotripsy or possible removal by endoscopic retrograde cholangiopancretography (ERCP) |
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Diagnose acute cholecystitis: The diagnosis of acute cholecystitis is based on the presence of at least two of three factors;
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• acute right upper quadrant tenderness
• fever higher than 99-5° F (37.5° C) or leukocytosis greater than 10,000/mm- • ultrasound evidence such as a thickened and edematous gallbladder wall, the presence of maximal tenderness elicited over the gallbladder, and pericholecystic fluid collection. |
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Cholecystitis: Diagnostics: Labs
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HCG in women of childbearing age
Amylase – if elevated >500U – consider pancreatitis ALT/AST (elevated) Alkaline phosphatase (elevated) Bilirubin (elevated) U/A CBC – expect leukocytosis in >70% patients |
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GBUS: Cholecystitis
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Highly sensitive and specific for GB disease – before ordering if symptoms suggest PUD, or gastritis would consider trial of PPIs for 2 weeks
Ultrasound can accurately detect cholecystitis in 95% of patients. |
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Cholecystitis: management and interventions
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Referral to surgeon if require narcotics
Acute cases remain NPO while transport to hospital Chronic presentations advise on low fat diets Consider watchful waiting in cases without biliary colic But in those cases with biliary colic (constant acute pain R shoulder or abd, with onset and resolution sudden, typically at HS, often with N/V), incidence of recurrence 50% annually and pt may likely benefit from surgery. |
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When do you use non surgical options for cholecystitis?
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Used for patients who are asymptomatic or poor surgical candidates
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What are the non surgical options for cholecystitis?
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Oral medications:
Drugs made from bile acid—including ursodiol (Actigall) (8-10mg/kg/day po divided qd-tid) used to dissolve the stones. These drugs work best on small (less than 20mm) cholesterol stones, and months or years of treatment may be necessary before all the stones are dissolved. Extracorporeal shockwave lithotripsy (ESWL): This treatment uses shock waves to break up stones into smaller pieces that can pass more easily through bile ducts and avoid blockages. However, intense pain can follow treatment, and the long-term success rate is not known. |
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What is the classic triad for acute uncomplicated diveriticulitis
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Classic triad: LLQ pain, fever, leukocytosis
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Assessment acute uncomplicated diverticulitis
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-Left lower quadrant pain (70-90% sensitive for diverticulitis)
-LLQ (localized) tenderness -hypoactive bowel sounds -distended and typanic abdomen -constipation or diarrhea -fever -nausea, vomiting -hx of diverticulosis - Negative FOBT -CT scan-liver, spleen, pancreas, adrenal glands, kidneys, gallbladder normal. Extensive diverticulosis of the descending colon. Sigmoid colon appears thickened in the distal portion; with fat stranding, no free fluid and no free air. |
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Assessment acute complicated diverticulitis
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-acute LLQ pain or diffuse pain
-Peritoneal signs: Distended and tympanic abd, Rebound tenderness, guarding, rigidity -hx of diverticulosis -low grade fever, chills Anorexia, n&v -elevated WBC Positive FOBT -CT results reveals abscess, fistula, free perforation Tenderness to site of pain, Palpable mass BoS depressed (exaggerated if obstruction) Dysuria if bladder involved (air or feces in urine if fistula) Rectal exam tenderness, mass Constipation or diarrhea |
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Malnutrition: Primary prevention
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Food pyramid food intake
Programs such as Meals on wheels Increased social environment for elders at meals to stimulate increased intake calories/nutrients Avoid meds if possible, which interfere with nutrients Multivitamin/mineral supplements for those unable to obtain in meals Avoidance of diarrheal illnesses when possible Increase caloric/nutritional intake with stress e.g. injuries, acute exacerbations of illnesses |
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Malnutrition: Secondary Prevention
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Regular recording of wt/height for early identification of deficits
Nutritional assessment on all high-risk individuals High index of suspicion with those at high risk and early wt loss |
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Malnutrition: Tertiary Prevention
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Inpt care for severe symptoms: anemia, dehydration, electrolyte imbalance, infections
Outpt care for stable individuals Manage cause of malnutrition if known: e.g. treat diarrhea, manage of chronic illness/stresses, stop offending medication or ETOH Also manage poorly fitting dentures, food inaccess, mouth pain, difficulty swallowing or chewing |
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Malnutrition: Symptomatology and assessment
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Wt loss
BMI <22 (this bears individualization) Wasting of fat store: centrally, peripherally and to face Loss of skeletal muscle (due to use of amino acids for gluconeogenesis) Dry skin Hair thin Dependent edema (anasarca) Skinfold measurements low |
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Malnutrition: Labs
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Labs may not be necessary in all cases:
those with alterations in labs may have increase risk for poor outcomes Decreased albumin Decreased lymphocyte count Chemistry for electrolyte imbalance eval Decreased BUN Also may consider: transferrin (L), essential amino acids (L), betalipoprotein (L), BS(L), cortisol (H), GH (H), insulin (L), hypersensitivity reactions (delayed) |
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Malnutrition: Management and interventions
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Adolescents and adults can be discharged when they are eating well and gaining weight,
they have a reliable source of nutritious food outside the hospital, and any other health problems have been diagnosed and treatment begun. Adults should continue to receive a supplemented diet as outpatients until their BMI is >18.5; for adolescents, their diets should be supplemented until their BMI-for-age is >5th percentile of the median NCHS/WHO reference values. |
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Fatigue: Primary Prevention
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Avoidance of overexertion
Regular physical activity Adequate sleep Weight management Adequate nutrition Stress management Psychiatric interventions |
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Fatigue: Secondary Prevention
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NONE
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Fatigue: Tertiary Prevention
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Dependent upon cause – See differential diagnoses
Heart disorders: CHF, neurally mediated hypotension Endocrine disorders: e.g. hypothyroidism Infections: endocarditis, hepatitis Respiratory disorders: COPD, sleep apnea Anemia Pain disorders: arthritis Others: cancer, alcoholism, drug side effects, MS, psychological conditions such as depression, somatization disorders Recent study: most often fatigue of unknown cause or psychiatric origin than to other causes However, be cautious not to miss these diagnoses! |
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Fatigue: Symptomatology and assessment: History to include
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Duration of fatigue
What seems to provoke the fatigue, awakening or strenuous activities? Level of fatigue e.g. able to continue activities or must rest? Does sleep relieve? ROS especially noting differential diagnoses symptoms Complete HPI – you are now experts in that technique |
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Fatigue: Management and interventions
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Dependent upon the findings from the history and physical exam
See individual diagnoses for care If no immediate diagnoses determined, consider Hg, ESR, electrolytes, TSH Consider Beck’s or similar depression inventory |
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****First rule of pain management is that the pain is _________.
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First rule of pain management is that the pain is whatever the patient says that it is.
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Primary prevention: Insomnia
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Insomnia is a symptom, not a diagnosis
May be attributable to poor sleep habits Sleep hygiene Awaken and bed at regular times Avoid napping Sleep environment should be quiet, stress-free, dark, somewhat cool Bed should be comfortable, only used for sleep/sex Exercise at least 6 hours before sleep (epinephrine) Avoid caffeine/etoh/nicotine/heavy night meal Go to bed only when tired Avoid emotional stim immediately prior to bed Sleep ritual: yoga, biofeedback, bath to promote sleep |
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When assessing a patient with insomnia its important to assess
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Assess for normal sleep patterns
sleep hygiene issue medical conditions psychological/physical/social events at time of onset Assess for treatment already used and success |
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Insomnia: Management and interventions
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Sleep hygiene measures – initiate 1-3 at a time
Sleep log: 24 hour logs for 1-2 weeks Treat underlying disorders e.g. GERD Use sedative/hypnotics sparingly, all but zolpidem alter various stages of sleep But caution with this med 2013 warning re: memory impairment If awake after 30 min attempt at sleep, to get out of bed and perform mundane task e.g. reading until feeling sleepy, then reattempt bed sleep Avoid clock watching Light evening snack may assist sleep NB: Chronotherapy: delay bedtime by 3 hours q night, until normal pattern resumed Light exposure 30-60 min before awakening, will help set circadian rhythm Short acting, short term hypnotics e.g. Zaleplon for insomnia in elderly |
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How many sleep hygiene measures should you initiate at one time
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1-3
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How long should you prescribe a sleep log for
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24 hour logs for 1-2 week
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How should you use sedative/hypnotics for in insomnia patients
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Use sedative/hypnotics sparingly, all but zolpidem alter various stages of sleep
But caution with this med 2013 warning re: memory impairment |
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What should you instruct a patient to do if they are awake after 30 minutes after attempting to sleep
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If awake after 30 min attempt at sleep, to get out of bed and perform mundane task e.g. reading until feeling sleepy, then reattempt bed sleep
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Warn patient to avoid ____ (action) when trying to sleep
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clock watching
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Chronotherapy*****
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delay bedtime by 3 hours q night, until normal pattern resumed
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Referral to Sleep Disorder Center when:
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Unable to control insomnia
Suspicion of underlying disorder such as narcolepsy or obstructive apnea |
