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243 Cards in this Set
- Front
- Back
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When you see difficulty in swallowing...what else should you look for?
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Weight loss
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What do you see with dysphagia ?
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Weight loss
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What if you see dysphagia and you don't know the diagnosis, what should you do first>
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Barium Study
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If you are in the stomach and see a pt. with dysphagia and wt. loss, what should you order first?
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Endoscopy
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When you are in the stomach and you see dysphagia what 2 esophageal disorders are endoscopy good for?
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1. Cancer
2. Barrett's esophagus |
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What do you have to do to confirm either cancer or Barrett's?
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Biopsy
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What is Barretts'?
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Precancerous histological change of the LES from squamous to adeno
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What 5 things should yo think of if you see the word dysphagia?
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1. Achalasia
2. Cancer 3. Web/Stricture 4. Zenker 5. Spastic |
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What are you thinking if you see a young (NON-smoker) with difficuly swallowing BOTH liq and solids at the same time?
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Achalasi
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What if you see a pt. with regurg food that pt. aspirates, but the difficulty in swallowing DOES NOT get worse?
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Achalasia
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What if you see a pt. with a nonprogressive form of dysphagia that is young and a non-smoker, what are you thinking ?
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Achalasia
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What is the best INITIAL test to do in Achalasia?
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Barium swallow
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What is the MOST accurate test to do in a pt. with difficulty swallowing BOTH liq and solid at the same time?
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Manometry
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IS Endoscopy the best test for diagnosing achalasia?
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NO---Manometry
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What will Manometry show in achalasia?
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Abs. of esophageal peristalsis (low pressure) and NORMAL or high LES pressure
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What is the problem in achalasia?
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LES doesn't relax
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Is ther a mucosal abnormality in achalasia?
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NO
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What is the diff in dysphagia and odynophagia?
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Dys==difficulty
Odyno--painful |
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What do you suspect if you see odynophagia?
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HSV, HIV, or Candida
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What is the best inital treatment for achalasia?
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Pneumatic dilation
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What if you do a pneumatic dilation and it doesnt' work in achalasia, what would you do next?
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surgery
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What if after informed consent pt. refuses dilation or surgery for achalasia, what can you offer?
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Botox
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How does Botox help in achalasia?
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Relaxes LES
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What if you see dysphagia with solids first adn then liquids, what are you thinking?
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Esph cancer
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What other finding might you see in Esoph cancer?
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Anemia
Heme-occult positive blood |
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What if you see a pt. >50 who are smokers/drinkers and have dysphagia what should you think?
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Esoph cancer
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What is the best initial test to do if you suspect a pt. with esophageal cancer?
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Endoscopy
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What if you can't order endoscopy to r/o Cancer d/t dysphagia, what else can you order?
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Barium swallow
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Will manometry be useful in diagosisng esoph cancer?
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NO
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What is the best Initial treatment for esoph cancer?
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Surgery
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What must you make sure before doing surgery on a esoph cancer patient?
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there is no local or distant mets
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What should you do if have esoph cancer and you do a surgical resection to make sure you eradicate the cancer?
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Give 5-flurouracil chemo
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What if you see dysphagia ad wt. loss, what should you think or?
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Esophagela pathology
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what should you think of if you see dysphagia and wt. loss, with hee-positive stool anmeia?
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Cancer
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Waht should you think of if you see repetive exposure of teh esophagus to an acid, or use of a sclerosing agent?
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Peptic strictures
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What is the best initial study if you suspect a peptic stricture?
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Barium swallow
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Why is variceal banding superior procedure than sclerosing agents for variceal bleeding?
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Sclerosing agents can lead to peptic strictures
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Waht are you thinking if you see a PROXima stricture with IRON def. anemia in a middle aged woman?
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Plummer vincent
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What d/o is plummer-vincent syndrom also assoc with
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Squamous cell esoph cancer
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What is the best inital therapy for Plummer vincent?
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Iron replacement
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What if you see a distal stricture with INTERMittent symptoms of dysphagia...what are you thinking?
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Schatzki ring
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What is the best intital treatment of Schaatzki ring?
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Pneumatic dilation
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What would you treat a stricture caused by repeated acid reflux?
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Pneumatic dilation
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What if you see a pt. with dysphagia and horrible BAD breath, what are you thinking?
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Zenker's Diverticulum
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What are you thiniing if there is a h/o food rotting in the back fo the esophagus?
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Zenker's Diverticulum
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What is the problem in Zenker's Diverticulum?
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dilation of the posterior pharyngeal constrictor muscles
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What is the best initial test on Zenker's Diverticulum?
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Barium study
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What is the best intiatl therapy of Zenker's Diverticulum
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surgical resection
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What are you thinking if you see severe CHEST pain and Ishcmeic heart disease risk factors and may occur after drinking a cold bev.and dysphagia may or may not be present?
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Diffuse esoph spasm or Nutcracker esophagus
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What is alway present in Diffuse esoph spasm or Nutcracker esophagus ?
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PAIN
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What if you see a distal stricture with INTERMittent symptoms of dysphagia...what are you thinking?
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Schatzki ring
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What is the best intital treatment of Schaatzki ring?
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Pneumatic dilation
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What would you treat a stricture caused by repeated acid reflux?
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Pneumatic dilation
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What if you see a pt. with dysphagia and horrible BAD breath, what are you thinking?
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Zenker's Diverticulum
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What are you thiniing if there is a h/o food rotting in the back fo the esophagus?
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Zenker's Diverticulum
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What is the problem in Zenker's Diverticulum?
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dilation of the posterior pharyngeal constrictor muscles
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What is the best initial test on Zenker's Diverticulum?
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Barium study
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What is the best intiatl therapy of Zenker's Diverticulum
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surgical resection
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What are you thinking if you see severe CHEST pain and Ishcmeic heart disease risk factors and may occur after drinking a cold bev.and dysphagia may or may not be present?
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Diffuse esoph spasm or Nutcracker esophagus
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What is alway present in Diffuse esoph spasm or Nutcracker esophagus ?
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PAIN
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Is dysphagia ALWAYS present in Diffuse esoph spasm or Nutcracker esophagus?
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NO
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What is the most accurate diagnostic test in Diffuse esoph spasm or Nutcracker esophagus/
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MAnometry
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What will barium studies show in Diffuse esoph spasm or Nutcracker esophagus
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Corkscrew Pattern
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when is corkscrew pattern seen on barium study for Nutcracker/Diffuse esoph spamsms?
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Only during the episode fo spasm
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What can you treat Diffuse esoph spasm or Nutcracker esophagus with ?
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CCB or Nitrates
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How will scleroderma present with ?
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Symptoms of reflux
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How will you treat dysphagia found in systemic sclerosis?
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PPI
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What is the most likely diagnosi in a pt. with odynophagia(HIV, HSV, Candida) and dyphagia in an HIV pt. with CD < 100?
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Candida
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Does esophagitis present with pain on swalloing or difficutly swallowing?
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Pain = Odynophagia
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What should you do first in a HIV neg. pt. with symptoms of odynophagia and you susupect esophagitis?
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Endoscopy
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What should you do in an HIV positvie pt. whom you see has odynophagia with a CD4 < 100 what should you do...treat or diag study?
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Treat with fluconazole
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What should you do in an HIV positvie pt. whom you see has odynophagia with a CD4 < 100 what should you do if fluconazole didnt work?
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Endoscopy
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What is the most common cause of esophagitis in an HIV positive pt>
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Candida
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What drugs would you tell pt. that it may cause esophagitis if they take it?
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Doxy or Alendronate
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What if a pt. on alendronate c/o of painful swallowing, what should you recommend?
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Sit up and drink more water when taking pill AND sty upright for 30 min after
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What if a pt. on doxy c/o of painful swallowing, what should you recommend?
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Sit up and drink more water AND sty upright for 30 min after
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What are you htinking if you see SUDDEN upper GI bleeding with retching an vomiting?
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Mallory-Weiss Tear
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What is the common progression in Mallory-Weiss Tears?
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Resolve spontaneously
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What should you do if you if bleeding persists in Mallory Weiss tears?
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give injection of Epi to stop the bleeding
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What do you do if a pt. c/o of Chest pain and unpleasant metalic taste, what should you do?
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Start PPI--think of GERD
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What other systemic disease presents like GERD and treated with PPI
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Scleroderma
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What if you get a pt. with epigastric pain, substernal chest pain, and you think GERD, what other things might be present...
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Sore throat
metallic taste/Bitter taste Hoarseness CHRONIC COUGH wheezing |
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Waht is the treatment and diagnosis of GERD?
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PPI
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When should you do 24-hr pH monitor if there is no response to PPI in GERD?
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24 hr. pH monitoring
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How do you treat GERD first?
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lifestyle modification:
Lose wt. Elevate HOB Quit smoking Limit alcohol, caff, choc, peppermint Don't eat 3 hours before sleeping |
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What if lifestyle modification don't work for GERD, what do you do?
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Start PPI
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When would you order a H2 blocker (cimetidine, rantidine, famotidine, nizatadine) in a GERD pt.?
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Only if the PPI didn't work
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Can metoclopramide be used for treatment of GERD? and is it commonly used?
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Yes
No, it's not commonly used |
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What if PPi and H2 blockers are not enough to control the disease, what can you offer?
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Surgical or endoscopy to narrow the Distal esophagus
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What is the histology of esophageal cancer?
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Adneocarcinom
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How can you diagnose Barretts' esophagus?
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Endoscopy b/c you can biopsy
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Who will you perform endoscopy on with what history?
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Anyone with wt. loss, heme-pos. blood, anemia OR
GERD for >5 yrs |
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Waht if you see Barrett's espoh on endoscopy, what do you do?
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PPI and repeat endoscopy Q 2-3 years
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What do you do if you see Low grade dysplasia
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PPI and repeat endoscoy in
3-6 months |
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What if you see High grade dysplasia on endoscopy, what do you do?
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Distal esophagectomy
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What if a 55y.o comes with epigastric pain for several weeks and no wt. loss, or no heme positive findings, what should you do?
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Endoscopy
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Why would you do an endoscopy first on a pt. that is 55y.o comes with epigastric pain for several weeks and no wt. loss, or no heme positive findings?
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B/c any pt. that is above 45 with persisten symptoms of epigastric discomfort should get it to r/o gastric cancer
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What is the most common cause of epigastric discomfort?
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non-ulcer dyspepsia
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What do you do first if you susupect a pt. has non-ulcer dyspepsia?
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Endoscopy
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What would you r/o in a pt. with epigastric pain by doing endoscopy?
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Ulcer ds
gastric cancer gastritis |
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What do you give for treatment if there is non-ulcer dyspepsia?
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H2 blocker
Liq antacid or PPI |
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What is the most common peptic ulcer cause?
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H. pylori
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Which peptic ulcer is assoc with gastric cancer?
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Gastric ulcers
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Which ulcer is better with food?
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Duodenal
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Which ulcer is worse with food?
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GAstric
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What shoudl you do if you have a pt. that is 60 and c/o epigastric pain?
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endoscopy to r/o gastric cancer
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What do you treat H.pylori with?
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2 antibiotics and PPI
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What if you see gastritis that does't improve with Hpylori treatment of PPI and 2 ABX, what should you think of ?
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Pernicious anemia with Vit B12 defic
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What should you think of if you see gastritis and Vit B12 defic?
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pernicious anemia
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If you susptect H.pylori, what is the MOST accurate test?
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Endoscopy with BX
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Is serology for H.Pylori more sensitive or specific?
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Sensitive
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What is a breath test and stool antigen test useful in determining for H.Pylori?
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new or old disease
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What is the treatment choice for H.Pyloir?
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Amox and Clarith with Omepra
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What if pt. is allergic to PCN for H.pylori treatment?
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Flagyl and Tetracy with Omepr
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Do you treat H.pylori if it is found without symptoms?
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NO
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What should you do if after amox/clarithro or flagyl/tetra meds don't work on H.pylori treatment, what should you do
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Look for ZE (gastrinoma)
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When should you order GI prophylaxis?
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Head trauma
Intubation Burn Coagulopathy and Std use together |
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Do you do GI prophylaxis in a pt. only on NSAID?
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NO
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Do you do GI prophylaxis in a pt. only on steroids?
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NO
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Is H.pylori the cause of non-ulcer dyspepsia?
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NO
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what if a 56 y/o male comes iwth epigastric pain and is +H.pylori but no ulcers, what should you do?
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Treat non-ulcer dyspepsia with PPI
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If ther are multiple ulcers found in the dista esophagus with 1-2 cm in size; what are you thinking?
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ZE
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What if you have a pt. with multiple ulcer disease that persist despit treatment for H.Pylori, what should you do?
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Eval for ZE
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How do you eval for ZE/
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look for Gastin level and Gastric acid output
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What will you find on a pt. on H2 blocker or PPI re: gastrin?
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Gastrin level will be high
but Gastic ACid LOW |
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How will ZE and H2blockr/PPI differ during workup?
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Gastrin level will be high in BOTH, but only ZE will have HIGH GASTRIC ACID
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When do you test for Gastrin level?
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>1 cm ulcer
multiple ulcers distal location near Lig of trieit Recurrent despite treatment |
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What are the most accurate test of ZE?
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Endoscopic U/S or
nuclear somatostatin scan |
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What is the nuclear somatostatin scan good for ZE?
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B/c they have an increase in the number of somatostatin Receptors
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What is the normal effect of infusing secretin IV?
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Normal people decrease GASTRIN and acid output
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What is the effect of infusing secretin IV in pt. with ZE?
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So no change in Gastrin and NO change gastic acid level
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What is teh treatment if it is a local disease?
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Surgical resection
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What is teh treatment if it is a metastatic disease?
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Lifelong PPI
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When should I look for MEN syndrom in a ZE pt.?
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Hypercalcemia--tells PTH
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What 2 disorders do you suspect if you see fever, wt. loss, blood in the stool, and abd. pain with diarrhea?
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UC and Chrons
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What IBD do you suspect if the pt. has fever, wt. loss, and abd. pain with BLOODY diarrhea?
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UC
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Can both UC and Chrons lead to colon cancer?
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YES, esp. if chrons involves teh colon
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If you see: Skip lesions you think?
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Chrons
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If you see: masses in transmural granulomas in IBD you think?
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Chrons
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If you see: fat malab. and hypocalcemia in IBD you think
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Chrons
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If you see: fistulae in IBD you think
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Chrons
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If you see: calcium oxalate kidney stones in IBD you think
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Chrons
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If you see: Vit B12 malabsorption from terminal ileum involveent in IBD you think
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Chrons
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If you see: perianal disease in IBD you think
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Chrons
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Waht arethe diagnostic test for IBD?
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Endoscopy and Barium studies
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Waht if IBD is not clear from endoscopy or barium study; what should you do?
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Blood test
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Waht IBD do you think of if you see anti-saccharomyces cervesiae (ASCA) positive Anti-neutrophil cytoplamic antibody (ANCA) negative??
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Chrons
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What IBD do you think of if you see Anti-neutrophil cytoplamic antibody (ANCA) positive andanti-saccharomyces cervesiae (ASCA) negative ?
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UC
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What is the best initial treatment for IBD?
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Mesalamine
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Why is sulfasalazine NOT the best inital therapy for UC or Chrons?
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Rash
Hemolytic Anemia Interstitial nephritis |
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What steroid would you use to control acute IBD flare up?
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Budesonide
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What is the first pass mech of budesonide and limits its systemic effects?
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Liver is it's first pass
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What if you have a pt. with severe chrons or UC woho have had recurrent disease when you stop the steroids, what can you give?
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Azathioprine and 6-MCP
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What should you give a Chron or UC pt. whom you want to wean off steroids?
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Azathioprine and 6-MCP
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What do you order for a Chrons pt. that has a fistula formation?
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Infliimab--TNF inhib
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Why do you order Infliximab for Chron's
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Holds the fistula granuloma in place
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What must you do prior to starting a Chron's pt on Infliximab?
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Do PPD test--screen for TB
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Why do you screen for TB in a chron's pt that has a fistula?
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B/c you will start them on Infliximab which can cause release of dormant TB from the granuloma
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What do you use to treat a Chron's pt. with perianal involvement?
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Flagyl and Cipro
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What do you recommend for a Chron's pt. if there are strictures or obstruction, and what must you tell teh pt. about recurrence?
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Surgery if stricture or obstruction and Chron's may recur at the sit of surgery
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What can be curative in Ulcerative colitis?
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Surgical removal of the colon
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When you see diarrhea, how many causes should you be thinking of?
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4
Infx/Bloody Non-bloody Antibiotic Chronic |
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What is the most common finding in Infectious diarrhe?
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BLOOD
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What bug are you thinking if you see bloody diarrhe?
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Campy
Shigella Salmonella E.coli Yersina Vibrio Vulnif and Paraheoly Amebic |
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What diarrhea infection are you thinking if you see Most common cause of food poisoning?
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Campy
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What diarrhea infection are you thinking if you see assoc with GBS
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Campy
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What diarrhea infection are you thinking if you see assoc with REiters?
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Campy
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What diarrhea infection are you thinking if you see eggs and chickens?
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Salmonella
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What diarrhea infection are you thinking if you see seafood?
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Vibrio Parahemolyticus
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What diarrhea infection are you thinking if you see HUS or undercooked beef?
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E. coli O157:H7
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What should you avoid if you think you have bloody diarrhea from E.coli O157
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Don't give ABx or platelet transfusion
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What diarrhea infection are you thinking if you see clams or oysters and liver disease or skin infection?
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Vibrio vulnificus
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What diarrhea infection are you thinking if you see Reiters syndrome
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Campy, Shigella
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What diarrhea infection are you thinking if you see rodents and they urinate on vegetables or meat, or milk products
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yersinia
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What if you suspect that bloody diarrhea infection are due to amebic, what should you do?
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3 stoob O/P
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What should you treat the ameobic infection with?
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Metronidazole
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What may the ameobic infection be assoc. with?
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liver abscesses
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What will fecal leukocytes in stool reveal?
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infection as the cause
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What is the first initial test when you see diarrhea?
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Fecal WBC
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What is the most accurate test for diarrhea?
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Stool culture
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how do you treat an infectious diarrhea that is mild?
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resolves on its ow
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Waht should you treat a diarrrhea pt. with fever blood, abdominal pain, and hypotension and tachy?
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Cipro or some fluorquinolone
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What if you have diarrhea that is non-bloody---what are you thinking?
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Virus
Girardia S.Arueus Bacillus cereus Crypto Scombroid |
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What non-bloody diarrhea are you thinking if you think of a virus?
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Rota or norwalk
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What non-bloody diarrhea are you thinking if you see camping/hiking and homosexual men?
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Giardia
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What non-bloody diarrhea are you thinking if you see camping wiht bloating, farting, adn fat malabsorb; what should you treat with?
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Metro (Flagyl) or
Tinidazole |
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What non-bloody diarrhea are you thinking if you see pt. with vomitting and diarrhea that goes away on it's own?
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Staph
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What non-bloody diarrhea are you thinking if you see refried Chinese rice
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Bacillus
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What non-bloody diarrhea are you thinking if you see HIV pt. with <100 CD4 what would you order to diagnose?
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modified acid fast stain
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What would you order in a pt. non-bloody diarrhea are you thinking if you see HIV pt. with <100 CD4 ?
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anti-retroviral drugs and
Paromomycin is only partially effective |
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What non-bloody diarrhea are you thinking if you see fish, tun, mackerel, mahi-mahi and they have V/D/wheeze/flushing
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Scombroid
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What do you treat What non-bloody diarrhea are you thinking if you see fish, tun, mackerel, mahi-mahi and they have V/D/wheeze/flushing?
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Benedryl
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What if you suspcet C-diff, what should you order?
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Stool toxin assy
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What is the best inital treatment for C-Diff?
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Flagyl
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What if Flagyl doesn't work for C.Diff treatment, what should you do?
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Oral VAnc
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Can you give IV Van for C.Diff diarrhea?
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NO, not useful
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What do you do if you successuflly treat a pt. with C-diff with Vanc and tehn gets it again?
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REtreat with Flagyl
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What do you suspect if a pt. c./o chronic diarrhea and farting what is the most common cause?
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Lactose intol
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what should be done to diagnose lactose intol?
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remove all milk and milk related products except yogurt
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What test can be preformed on a lactose intol pt.
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Lactose intol test
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What if you see diarrhea with flushing and episodes of hypertension, what should you think of?
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Carcinoid syndrom
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What if you see a pt. with diarrhea, flushing, and episodes of hypotension what should you diagnose the pt. with?
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Urinary 5-HIAA level
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What should you treat a pt. with diarrhea, flushing, and episodes of hypotension?
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Octreotide (somatostatin analogue)
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What do you suspect when you see "foul smelling" stool and oily greasy stool...what type of malabsorbion?
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Fat malabsorb= steatorrhea
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What 4 diseases are assoc. with fat malab?
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1. Celiac
2. Tropical sprue 3. Chronic Pancreatitis 4. Whipples |
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What are the findings assoc with fat malabsorb re: Ca, oxalate, PT/INR, and vit B12?
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Ca is low from Vit D defic
Oxalate kidney stones Easy bruising--vit K malab VitB12 malab--terminal ileum destruction or loss of panc enzymes necessary for Vit B12 absorption |
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What is the best inital test for pres. of fat
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Sudan black stain
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Waht is teh most sensitve test for malabsorption
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72-hours fecal fat
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What are you thinking if you see with malabsorption of iron and microcytic anemia?
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Celiac disease
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What are you thinking if you see vesicular lesions on the skin but not mucosal surfaces and assoc. with malabsorption?
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Dermatitis Herpetiformis assoc with Celiac disease
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Can you get folate malab with celieac disease?
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yes
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What do you think of if you see anti-gliadin Ab?
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Celiac
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What do you think of if you see anti-endomyseal Ab/
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Celiac
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What do you think of if you see anti-tissue transglutaminase AB?
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Celiac
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What is the most accurate test for celiac disease/
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Small bowel biopsy
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What do you think of if you abnormal D-xylose is abnormal?
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Celiac disease, Whipples, and tropical sprue
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Do you have to do a bowel biopsy for celiac sprue? Why?
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yes--to r/o bowel wall lymphoma
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What is the treatment for celiac sprue?
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Eliminate wheat, oats, ry, and barley
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How long do you have to tell your pt. that they can expect ot see results?
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several weeks
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A pt. comes wiht malabsorption of iron, mircocytic anemia, folate defic, steatorrhea, and recently came from Brazil with anti-tissue transglutaminase negative...what are you thinking?
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Tropical sprue
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What is the most accurate test for tropical sprue?
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Small bowel biopsy showing microorganisms
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Waht do you do if you have a pt. with steatorrhea and neg. anti-endomyseal Ab. that has micororganisms on small bowel biopsy?
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Treat with Tetracycline or Bactrim
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How long do you give treatment for Tropical sprue and what is the treatemnt?
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Bactrim or tetracycline
for 3-6 months |
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What if you have a pt. with steatorrhea, foul smelling stool, joint pain, neuro prob adn occular findings what is the most accurate test?
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small bowel bpsy showing PAS postitive organisms
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What if you can't do a small bowel biopsy in a pt. you are thinking has Whipples disease, what should you do?
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PCR of the stool ---Trophyrema Whippeliei
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How do you treat Whipples' and for how long?
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Bactrim or Tetracyclin for 12 months
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In chronic pancreatitis, will you see elevated levels of amylase and lipase?
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NO
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when do you start to see steattorhea in pancreatitis
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When the pancreas is burned out and parenchyma is fibrosed
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Do you see more Vit D and Vit K defic in chronic pancreatitis than celiac disease?
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NO--it is actually less than celiac disease
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What is the best inial diagnostic test to do in a an alcoholic that comes in with a few months of foul smelling stool?
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Ab Xray--look for pancreatic calcifications
Ab CT--more sensitve |
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What is the most accurate test in chronic pancreatitis?
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Secretin stimulation testing--
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What happens when you infuse a large amount of secretin in a normal pt?
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Release a large amount of bicarb
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What will you find in chronic pancreatitis re: iron and folate levels?
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Iron and folate will be normal b/c dont' need pancreatic enzymes to absorb
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What will your D-xylose test be in chronic pancreatitis?
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Normla
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What do you do to treat chronic pancreatitis
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ORAL panc. enzyme replacement (amylase, lipase, trypsin)
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What are you thinking if you see pt. with Abdominal pain and relief with defecation?
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Irritable bowel
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What are you thinking if you see pt. with Abdominal pain that is LESS at night?
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irritable bowel
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What are you thinking if you see pt. with Abdominal pain with diarrhea alternating with constipation?
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Irritable bowel
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What would you order on CCS if you think pt. has irritable bowel syndrome?
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Stool guiac, WBC, O/P, culture
Colonoscopy Ab CT |
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What is the best intial treatment?
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Fiber
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What if fiber doesn't work for Irrit Bowel, what woud you suggest?
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anti-spasmodic or anticholiner
(Dicyclomine or Hyoscyamine)--it relaxes the bowel |
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What if you have a pt. you are treating for irritable bowel and you gave her fiber, dicycloamine, and still there is no response, what would you do next?
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give TCA antideprssant---amytriptyline
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Why does amytriptiline work in Irritable bowel?
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it is anticholinergic
relieves neuropathic pain anti-depressant |
