Osce Review: Gi

Front 1

What are 4 drugs, their pharm categories and doses used to treat N/V?

Back 1

1. Diphenhydramine (benadryl), anticholinergic, 10-50mg PO prn
2. Prochlorperazine (Compazine), phenothiazine, 5-10mg PO q6-8hrs
3. Metoclopramide (Reglan), substituted benzamide, 5-10mg PO/IM/IV q6-8hr
4. Ondansetron (Zofran), 5HT3 antagonist, 16mg PO x1

Front 2

What is cholelithiasis and what is the MC type?

Back 2

*gallstones
*MC type: cholesterol

Front 3

What are the 5 Risks for cholelithiasis?

Back 3

5 F's
*fat *40 *female *fertile
*fair *flatulence

Front 4

What are the symptoms of cholelithiasis?

Back 4

*radiates, comes/goes, worse after eating

*Charcot's triad: RUQ pain, jaundice, fever (more with choledocolithiasis or cholangitis)

Front 5

What are the signs for cholelithiasis?

Back 5

*+ Murphy's sign (pain on palpation)
*inspiratory arrest

Front 6

How do you dx & tx cholelithiasis?

Back 6

*dx: US
*Tx: pain meds, elective cholecystectomy, or ESWL (lithotripsy w/ large stone)

Front 7

What is cholecystitis?

Back 7

*sudden GB inflammation dt outlet obstruction (stones)

Front 8

What are the s/s of cholecystitis?

Back 8

*Sx: fever, pain, radiate, duration of 6h or more, SUDDEN
*Signs: + murphys

Front 9

How do you dx & tx cholecystitis?

Back 9

*Dx: US
*Tx: NPO, IV fluids, IV Abx (3rd gen cephs + metro), surgery
*Pt Ed: small meals, decrease fat

Front 10

What is choledocolithiasis?

Back 10

*stones in the Common Bile Duct
*can lead to cholangitis

Front 11

Choledocolithiasis what are:
1. sx
2. tx

Back 11

1. pain, +/- pancreatitis
2. surgery, ERCP (enteroscopic retrograde cannulation of pancreas)

Front 12

What is cholangitis?

Back 12

*Life-threatening
*ascending infection of extra-hepatic ducts

Front 13

What are S/S of cholangitis?

Back 13

*Charcot's triad: RUQ pain, fever, jaundice
*F/C, N/V, sepsis, RUQ tender

Front 14

Tests and labs for cholangitis

Back 14

*CBC, increased LFTs, increase bilirubin
*US, ERCP = best

Front 15

Tx for cholangitis

Back 15

*IV fluids, Abx, analgesics
*ERCP when stable
*cholecystecomy after acute episode

Front 16

Define pancreatitis. WHat are the MCC for F/M?

Back 16

*inflamm of pancreas (high mortality)
*F: stones
*M: EtOH

Front 17

S/S of pancreatitis

Back 17

*Rapid onset
*severe epigastric pain
*radiates to back
*constant/boring/severe
*better leaning forward/sitting
*decreased/absent bowl sounds

Front 18

What would indicate a poor prognosis with pancreatitis?
How do you diagnose it?

Back 18

*Poor prognosis: hypovolemia, ARDS, tachycardia
*Cullen's blue periumbilical, Gray Turner = colored flanks
*Dx: CT or US, Ranson's criteria

Front 19

What is the Tx for pancreatitis?

Back 19

*NPO x 48hr
*admit
*pain mgmt (opioids are CI, therefore use meperidine)

Front 20

What are the risks and sx of pancreatic CA?

Back 20

*75% in head
*risks: EtOH, chronic pancreatitis, age, obesity
*sx: vague/diffuse epigastric/LUQ pain

Front 21

What is cirrhosis?

Back 21

*endpoint of liver dz
*inflamm of the liver
*irreversible

Front 22

Causes of cirrhosis

Back 22

*EtOH, Hep C, NAFLD

Front 23

S/S of cirrhosis

Back 23

*firm nodular liver *jaundice
*spider angioma *palmar erythema *pitting edema
*bruising *fetor hepaticus (breath of death) *ascites
*Caput medusa *HPM
*esophageal varices
*gynecomastia

Front 24

Labs for cirrhosis

Back 24

*increase LFTs (GGT = EtOH)
*decreased BUN
*increased ammonia
*decreased albumin/increased INR
*increased bilirubin

Front 25

Tx of cirrhosis

Back 25

*liver transplant
*avoid EtOH, tx underlying dz
*give thiamine/folate *low protein diet *CS

Front 26

Complications of cirrhosis

Back 26

*portal HTN, variceal bleeding, ascites, coagulopathy, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome

Front 27

Hepatitis A
1. cause
2. s/s
3. tests

Back 27

1. A = ass, self-limited, contagious 2-3wks
2. asx, N/V/D, jaundice, anorexia, RUQ pain, fatigue
3. +IgM = infxn, +IgG = immunity, IgM-anti-HAV = 3-4wks, IgG-antiHAV @2 mo
3.

Front 28

Hepatitis A
1. tx
2. Prevention

Back 28

1. supportive, reportable
2. vaccine >20yo, handwash, contagious 7d after onset of jaundice, prophylaxis w/in 14d of exposure

Front 29

Hepatitis B
1. Cause
2. S/S

Back 29

1. B = blood (Hep D only w/ Hep B)
2. joint pain, rash, jaundice, RUQ pain, fatigue, anorexia, N/V

Front 30

Hepatitis B
1. tests

Back 30

*HBsAg = infxn
*HBcAg = virus in liver
*HBeAg = contagious (replicating)
*antiHBs = immunity
*anti-HBc = exposed (carrier)
*anti-HBe = trying to decrease viral load

Front 31

Hepatitis B
1. Tx

Back 31

*Acute: supportive, report, vaccine
*Chronic: interferon
*post-exposure prophylaxis: unvaccinated = vaccine + HBIG, vaccinated = booster of HBIG if anti-HBs <10

Front 32

Hepatitis C
1. info
2. Tests
3. Tx

Back 32

1. C = chronic, IV drugs, MCC of chronic hepatitis
2. increased ALT/AST, RNA + = current infxn, Anti-HCV: - for most, then + for life
3. Tx: interferon, avoid EtOH/APAP, HBIG

Front 33

GERD
1. why a concern?
2. MC sx?
3. Other s/s

Back 33

1. Change to Barrett's esophagitis (precursor to CA)
2. MC sx = heartburn
3. worse: laying, post-eat, foods (spicy, EtOH), dec. LES (smoking, obesity, Pg)
*Better: elevate HOB, small meals

Front 34

When should an endoscopy occur?

Back 34

*CC dysphagia
*>45 w/ new sx
*recurring sx
*no relief w/ meds
*alarming sx (anemia, N/V, severe pain, decreased wt, GI bleed, >55)

Front 35

What meds make GERD worse?

Back 35

*BB, CCB, nitrates, anticholinergic, sedatives, bisphosphonates, estrogen

Front 36

What are the various tx for Phase I, Phase IIA, Phase IIB, Phase III for GERD?

Back 36

*Phase I (mild/intermittent): antacids or OTC
*Phase II (sx): Rx H2RA or PPI
*Phase IIB (mod-severe sx): high dose H2RA or PPI
*Phase III: surgery/endoscopic tx

Front 37

What are lifestyle changes for GERD?

Back 37

*lose weight *avoid tight clothes *eat small/protein meals *no food w/in 3hrs of bed *no smoking *decrease chocolate, EtOH, caffeine, mint, fat *elevate HOB

Front 38

GERD pharm tx with Antacid
1. Name
2. category
3. AE

Back 38

1. Calcium Carbonate (Tums), Aluminum hydroxide (Maalox), Magnesium hydroxide (Mylantin)
2. Antacid
3. Ca/Al = constipation, Mg - diarrhea

Front 39

GERD pharm tx w/ H2RA
1. name
2. category
3. dose
4. AE

Back 39

1. Ranitidine (Zantac)
2. H2RA
3. 150mg BID x 6-12 wks (8-12 for phase IIB)
4. AE: D/N/V

Front 40

GERD pharm tx w/ PPI
1. name
2. category
3. dose
4. AE

Back 40

1. Omeprazole (Prilosec)
2. PPI
3. 20-40mg QD x4-16wks
4. can increase infxn risk, D/N/C, HA, rash....taper when d/c

Front 41

Gastritis:
1. sx
2. types
3. tx

Back 41

1. epigastric pain, N, anorexia, dyspepsia - inflamm of stomach
2. *erosive/hemorrhagic (NSAIDS/stress/EtOH) *atrophy/non-erosive (H.pylori) *Specific (eosinophilic/infxns)
3. antacids, H2RA, PPI, sucralfate (Carafate - coats inflamm area), moderate- severe = eval for PUD

Front 42

PUD sx

Back 42

*epigastric pain (gnawing, burning, non-radicular)
*sx free periods

Front 43

Causes of PUD, MCC?

Back 43

*NSAIDs & H. pylori
*MCC: H. pylori

Front 44

Key difference between gastric and duodenal ulcers

Back 44

*Gastric: worse after meal (anorexia), increased risk of CA, requires proof of healing
*Duodenal: pain after 2-5hrs (eat = better w/ food), wakes pt up at night, assoc w/ H. pylori

Front 45

Causes of NSAIDS induced ulcer

Back 45

*CHAAP BASI
-CS use -high dose NASIDS
-antiplts (ASA) -anticoags
-prior PUD -bisphosphonates
-age >60 -SSRI use
-immune compromised

Front 46

How to test for H. Pylori

Back 46

*UBT *endoscopy
*fecal antigen

**UBT/stool: false - w/ Abx or bismuth in 4 wks, PPI w/in 2 wks

Front 47

Tx for H. pylori induced ulcer

Back 47

*PPI + Amoxicillin (Amoxil) 1g BID x 5 d
*PPI +clarithromycin (Biaxin) 500mg BID + tinidazole (Tindamax) 500mg BID x 5d
*continue PPI 2 wks
*confirm cure >8wks after tx complete

Front 48

Tx for H. pylori NEGATIVE ulcer

Back 48

*H2RA (6-8 wks), PPI (4wks)
*Gastric Ulcer = tx longer/higher dose

Front 49

Assessing NSAIDs Risk & Alterations:
1. Low risk
2. MOderate Risk
3. High Risk
4. Very high risk

Back 49

1. N-NSAID or partially selective
2. (1-2RF): cox-2 inhibitor OR N-NSAID + PPI or misoprostol
3. (>3RF): N-NSAID or cox-2 + PPI or misoprostol
4. (prior ulcer): N-NSAID or cox-2 + PPI + misoprostol

Front 50

What is the difference between diverticulosis and diverticulitis?

Back 50

*diverticulosis = outpouchings of colon
*diverticulitis = infxn & inflamm

Front 51

1. What age is diverticulitis MC in?
2 What part of colon is MC affected?

Back 51

1. >50yo
2. sigmoid

Front 52

S/S of diverticulitis

Back 52

*Triad: LLQ pain, fever, leukocytosis
*pain worse after eating, increases w/ BM
*look acutely ill, tender, F/C, N/V, decreased bowel sounds

Front 53

Tests/Labs for diverticulitis

Back 53

*CBC *lytes *LFTs/amylase/lipase *UA
*CRP >200 = increased risk of perf *CT = thickend bowel walls/inflammed
*colonoscopy 6-8wks post recovery

Front 54

Diverticulitis
1. Outpt tx
2. inpt tx
3. pt education

Back 54

1. clear liquids X48hrs, broad spectrum Abx (Cipro + metro, Moxi, Amox/Clav), F/U colonscopy
2. NPO, Abx = IV, pain mgmt
3. increase fiber & water

Front 55

Colorectal CA
1. stats
2. Risks

Back 55

1. 3rd MC CA
2. PMHx/FHx, IBD >10yrs, CRC/polyps, obese/inactive, DM, processed red meat/decreased fiber, EtOH/smoking, Female w/ endometrial/ovarian CA

Front 56

Screening for CRC (colorectal CA)
1 Start & F/U
2. types of screening

Back 56

*start @ 50yo, then q10yrs (AA= 45 yo, FHx = 40yo)
*colonoscopy (gold std), FOBT qyr, Flex sig q5yr, double contrast barium enema q5yrs

Front 57

1. What are hemorrhoids?
2. When do they hurt?

Back 57

1. swollen/stretch veins in anal canal dt increased pressure
2. dentate line marks internal versus external, below = OUCH!

Front 58

Sx of Hemorrhoids

Back 58

*MCC of hematochezia (BRBPR)
*burn *pain w/ BM

Front 59

Tx of hemorrhoids
1. external
2. internal

Back 59

1. increase fiber/H2O, sitz bath, steroid creams, don't strain, stool softner Docusate (Colace) Emollient Laxative, 100mg BID
2. band ligation w/ anoscope, scleropathy

Front 60

Diarrhea Characteristics
1. small bowel
2. large bowel
3. secretory
4. exudative
5. osmotic
6. other

Back 60

1. H2O, larger volume, pH <5.5
2. mucoid/bloody, small volume
3. lot of volume
4. inflammatory
5. nutrient pull H20 into poop
6. altered transit time, persistent >14d

Front 61

What are 2 major causes of diarrhea?

Back 61

*infection: viral (MC), bacterial, parasites
*Drug-induced: laxatives, antacids (Mg), cholinergics

Front 62

Tx of Diarrhea
1. diet change
2. bacterial replacement

Back 62

1. clear liquids x24hrs, no solids/dairy x24hr, N/V = low residue, BRAAT (bananas, rice, apples, applesauce, toast)
2. lactobacillus, acidophillus, dairy products

Front 63

Pharm tx of Diarrhea
1. Anti-motility
2. Anti-secretory

Back 63

1. Loperamide (Immodium) 4mg x1, then 2mg PO after BM
2. Bismuth subsalicylate (Pepto-Bismol) 2 tabs PO q1hr prn (caution w/ kids dt Reye's)

Front 64

What are 4 different causes of constipation?

Back 64

*decreased fiber
*meds (opioids, anticholinergic)
*functional
*Dz (CD, Parkinson, MS, CVA)

Front 65

Red Flags for Constipation

Back 65

*acute onset *wt loss
*N/V/D *rectal pain *bleeding
*decreased caliber of stool
*melena

Front 66

Tx of constipation
1. Non-pharm
2. Pharm

Back 66

1. increase fiber & fluids
2. Psyllium (Metaucil), bulk forming, Docusate (Colace), emollient laxative 100mg BID, Bisacodyl (Dulcolax) stims gut motility, glycerin = good for kids

Front 67

IBS
1. info
2. risks
3. dx

Back 67

1. change in bowels w/o underlying problems
2. women, young (15-30), psych issues
3. ROME criteria: ab pain >3d/mo x3mo with 2 of the following: better w/ poop, change in stool form, change in frequency

Front 68

IBS Tx

Back 68

*Chronic constipation:
-Lubiprostone (Amitiza) Cl channel activator
-Tegaserod (Zelnorm) (CV events)
*Diarrheal IBS:
-Alosetron (Lotronex) (serious GI effects)

**fiber, probiotics, TCA/SSRI, psych tx = GOOD

Front 69

IBD
1. when is it usu dx?
2. How is it dx?

Back 69

1. 15-30yo
2. colonoscopy or EGD

Front 70

Ulcerative Colitis (UC)
1. location
2. thickness of lesions
3. pattern of lesion
4. complications
5. dx
6. changes on xray
7. sx

Back 70

1. rectum
2. mucosal/submucosal
3. continuous lesion
4. increased CA risk
5. pANCA
6. lose haustral mark, friable appearance
7. bloody diarrhea

Front 71

Crohn's Dz (CD)
1. location
2. thickness of lesion
3. pattern of lesion
4. complications
5. dx
6. xray changes

Back 71

1. terminal ileum (MC), anywhere
2. transmural
3. skip lesions, cobblestone
4. fistulas, Vit B12 deficient
5. ASCA
6. string sign

Front 72

Tx of IBD (Crohn's & UC)

Back 72

*decrease caffeine & gasy veggies
*supplement Vit B12 & Fe
*mild-moderate dz: 5-ASA (sulfasalazine, asacol, pantasa)
*Abx w/ perianal dz (CD)
*mod-severe dz: glucocorticoids
*surgery = cure for UC

Front 73

Bowel Obstruction
1. SBO vs LBO causes
2. sx
3. PExam
4. tx

Back 73

1. SBO = adhesions, LBO= CRC
2. VODKA (vomit, obstipation, distension, krampy, ab pain)
3. hypertympanic w/ percuss, auscultate = tinkling, AXR: distended, air/fluid levels
4. NG tube suction, IV fluids, NPO, admit

Front 74

Appendicitis
1. age
2. sx

Back 74

1. 10-30 yo
2. anorexia, low-grade fever, RLQ pain (migrates from umbilicus)

Front 75

Appendicitis signs

Back 75

*RLQ tender @ McBurneys
*rebound tenderness/guarding
*heel thump +
*obturator (IR of R flexed leg)
*Psoas (pain w/ R thigh extension)
*Rovsings (pain when LLQ palpated)

Front 76

Labs for Appy

Back 76

*WBC = increased
*US if Pg
*CT (oral contrast)

Front 77

Tx for Appy

Back 77

*surgery
*pain meds
*Abx for prophylaxis

Front 78

Hernia Types
1. Direct
2. Indirect
3. Femoral

Back 78

1. through inguinal canal, pushs on fingerpad
2. MC, follows course of inguinal canal, push on fingertip, ONLY in men
3. through femoral canal, MC in women

Front 79

Hernia Tx

Back 79

*reduce
*surgery for incarcerated (can't reduce) or strangulated (no blood to tissue)

Front 80

What differentiates UGI bleed from LGI bleed?

Back 80

*UGI: above the ligament of Treitz (duodenum and up)

Front 81

Sources of UGI bleed

Back 81

*epistaxis, esophageal varices, Mallory-Weiss tear, PUD
*PUD = MCC*

Front 82

Sources of LGI bleed

Back 82

*CA, AVM, IBD, hemorrhoids, anal fissure, diverticulosis

**MCC = diverticulosis**

Front 83

Labs for UGI or LGI bleed

Back 83

*vitals
*Hgb (nl until add fluids)
*FOBT

Front 84

Tx of UGI or LGI bleed

Back 84

*Primary: O2 + monitor, volume replace, NG tube w/ sig bleed
*Secondary: locate bleed
-UGI: UE
-LGI: sigmoid/colonoscopy

Front 85

Define:
-melena
-BRBPR
-hematochezia
-hematemesis

Back 85

*melena: dark tarry stool (UGI bleed w/ slow transit)
*Blood (MC w/ hemorrhoid)
*same as BRBPR
*coffee ground emesis