Nurs 623 exam 2023-24 with correct answers

Nurs 623 exam 2023-24 Anxiety disorder - correct answer Most common psych disorder in the US (usually 20-45year olds) Symptoms manifested in several ways: •Affective •Behavioral •cognitive •Somatic More common in women Thinks to rule out with anxiety - correct answer thyroid issues palpitations drug use caffeine diagnostics for anxiety - correct answer blood chemistry ekg thyroid function Symptom criteria for diagnosis of GAD - correct answer Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) Clinical Presentation of GAD Excessive anxiety Hyper vigilant Headaches Restlessness Shakiness Hyperactive autonomic symptoms Disrupts life Symptoms for 6 months or more Education for GAD - correct answer •Avoid alcohol and stimulants •Symptom recognition •Symptom interpretation Treatment for GAD - correct answer Non pharmacologic •***Cognitive behavior therapy (CBT) Pharmacology •Anti-anxiety agents (refer to text for list) •Acute: alprazolam and diazepam short term •Long term: SSRIs •*caution in elderly Panic disorder - correct answer An anxiety disorder marked by unpredictable minutes-long episodes of intense dread in which a person experiences terror and accompanying chest pain, choking, or other frightening sensations. Distinguish between disorder and attack •Pattern of recurrent episodes •Sudden onset •Severe symptoms Diagnosis: based on clinical symptoms •Refer to text for symptom criteria Treatment: •SSRI/SNRI or TCA •CBT** PTSD (Post Traumatic Stress Disorder) - correct answer Types PTSD •Acute: <3 months •Chronic: >3 months •Delayed: onset at least 6 months after trauma Clinical •Symptoms are apparent for greater than one month Symptoms: intrusive, avoidant behaviors, hyper arousal. education and treatment for PTSD - correct answer Pharmacology -SSRI -Paroxetine and sertraline -? prazosin Non-pharmacological •CBT and prolonged exposure (PE) •Critical incident debriefing (CID) •Stress inoculation therapy (SIT) •Image rehearsal therapy (IRT) •Psychodynamic Therapy •Family, group, and peer Major depressive disorder - correct answer Characteristics •Severe negative change in mood, thinking, and behavior •Severity •With or without suicide idealization Epidemiology •5-20% of population •Adults >65 (30-40%) •High rate for recurrence •Women > Men •8-19% hospitalized •1 out of 7 suicide •Co-morbid anxiety, cardiac and diabetes Differential diagnosis for major mood disorder - correct answer Thyroid disorder •Sleep disorder •Unrecognized bipolar •Neurological •Medications •Substance use •Adrenal functioning Clinical features of Major depressive disorder - correct answer The DSM-5 symptom criteria for major depression state that five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms is either (1) depressed mood or (2) anhedonia, meaning loss of interest or pleasure: • Depressed mood expressed as feelings of sadness or hopelessness. Irritability may be the primary symptom in adolescents and children. • Markedly diminished interest (apathy) in most activities. • Change in appetite. • Insomnia or hypersomnia. • Behavioral agitation or retardation. • Loss of energy. • Feelings of worthlessness or guilt. • Loss of concentration. • Recurrent thoughts of death or suicide. • These symptoms cause significant functional impairment and are not related to a medical illness or from the effects of a substance. Risk factor for major depression - correct answer Age: Adolescent or older adult Gender: Female Family History: Strong family history of depression, suicide or attempt, alcohol abuse, or other substance abuse History: History of migraine headaches, back pain, recent myocardial infarction, and/or peptic ulcer disease Current Medical Condition: Current chronic disease (especially multiple diseases) Lifestyle: Insomnia Stress Poverty Less than high school education Recent traumatic event Parent or caregiver of a child or children with behavioral disorders, especially hyperactivity Retired What are the common presenting symptoms of depression in the geriatric patient? - correct answer •Vegetative—poor appetite, disrupted sleep, early morning awakening •Somatic—pain throughout body or out of proportion with underlying pathology •Psychological—obsessive feelings of guilt and worry, ruminations throughout the night; suicidal ideation; memory problems •Psychomotor— anxiety; psychomotor agitation •Diurnal variation in symptoms—cannot "get moving" in morning, or specific time of day when depression is worst pharmacologic treatment for major depressive disorder - correct answer Selective Serotonin Reuptake Inhibitors (SSRIs) Advise patients that antidepressant effect may take from 4 to 8 weeks (up to 12 weeks) to manifest. SSRIs are also first-line therapy for elderly patients because they have fewer side effects *Contraindications Avoid SSRIs within 14 days of taking an MAOI (serotonin syndrome) • Fluoxetine (Prozac): Longest half-life of all SSRIs and the first SSRI (useful for noncompliant patients) • Paroxetine (Paxil): Shortest half-life • Citalopram (Celexa): Has fewer drug interactions compared with other SSRIs • Escitalopram (Lexapro): Compound derived from citalopram (Celexa) Other SSRIs: Sertraline (Zoloft), fluvoxamine (Luvox postpartum depression - correct answer Recognize it is a real MMD Risk: •Few days after delivery up to six months after childbirth Support groups- can use low dose SSRI's while breastfeeding. How do you assess suicide risk (consider mnemonic SAD PERSONS)? - correct answer • The five basic steps are to clearly define the problem; identify risk and protective factors; develop and test interventions; implement interventions; and evaluate effectiveness. • Careful assessment of suicide risk factors, willingness to consult with other practitioners and specialists, and planning are the hallmarks of effective suicide risk management • The assessment should cover the patient's recent personal history and pay special attention to recent stressful life events and changes in mental status. Reports of recent losses, humiliations, demoralizing experiences, substance use and abuse, and relationship problems should be explored. • One of the most valuable assessment tools for practitioners is the willingness to question a patient directly about his or her suicide risk. o Two good general questions are "How long can you go on the way you are?" and "Are you feeling so badly that you sometimes wish you could go to bed and not wake up?" o Examples of more specific questions are "What is your plan for suicide?" and "Have you assembled what you need?" SAD PERSONS stands for ________. What is the scale of risk? - correct answer Sex, age, depression, previous attempt, ethanol abuse or recreational drugs, rational thinking loss, social support loss, organized plan, no spouse, availability to lethal means, sickness, concept of mood lifts Acute suicide risk education and follow up - correct answer Education •Avoid alcohol •Family and patient: when mood lifts with antidepressant treatment, there is an increased risk of suicide attempts Follow-Up •Involve mental health care provider •Refer therapy •Monitor closely •Involve supports What is the difference between major mood disorders (unipolar) and bipolar disorders I and II - correct answer Unipolar (major depressive disorder) characterized by a history of one or more major depressive episodes and no history of mania or hypomania Bipolar I have had at least one episode of true mania preceded by or followed by hypomanic OR a major depressive episode A major depressive episode is not required for the diagnosis. Bipolar II is characterized by recurrent depression AND hypomania. NO history of a mania episode. psychotic disorders - correct answer a group of psychological disorders marked by irrational ideas, distorted perceptions, hallucinations, self care deficits, and a loss of contact with reality stages of grief according to Kubler-Ross and the correct order - correct answer Denial - conscious or unconscious refusal to accept facts, information, reality, etc. Anger - upset with self or others, especially those close to them Bargaining - attempting to bargain with whichever god the patient believes in. Less serious trauma can seek to negotiate compromise i.e. "can we still be friends" after a break up Depression - also known as preparatory grieving. Sadness, regret, fear, uncertainty, etc. starts to show acceptance Acceptance - indication there is some emotional detachment and objectivity grief management - correct answer Acknowledge feelings are normal Offer comfort but know limitations Encourage support system - sometimes its just a manor of listening Consideration for prescribing medication: Brief use of tranquilizer SSRI may help Avoid tranquilizers long term How would you identify intimate partner violence? - correct answer ***Know that abuse can include mental/verbal/physical. It can accelerate over time, and access to weapons can lead to fatality. The first goal of assessment is to determine whether or not an individual is a target of violence. The second goal is to evaluate the level of danger. The patient must be seen alone! PERPETRATOR -Humiliates their partner -Criticizes partner -Blames the victim for their abusive behavior -Acts jealous and possessive -Limits partners access to money, phone, car VICTIM -Feels afraid of their partner -Avoids certain topics out of fear of angering partner -Feels they deserve to be hurt or mistreated -Feels emotionally numb or helpless domestic violence red flags and assessment - correct answer • Look for symptoms or behaviors that may signal abuse such as exacerbation or poor control of chronic illness, sleep disturbances, chronic pain, or frequent unexplained appointment changes. • Behavioral red flags are (1) a patient who is reluctant to speak in front of her partner or gives evasive answers and (2) an overly protective or controlling partner. • Any patient presenting with multiple complaints or whose symptoms are not consistent with her history should be assessed for violence at least once and reassessed if she fails to respond to therapy appropriately. • Questions to ask: o Have you been hit, kicked, punched, forced to have sex, or otherwise hurt by someone within the past year? If so, by whom? o Do you feel safe in your current relationship? o Do you feel threatened or controlled by a partner or ex-partner or anyone else in your life? Anorexia nervosa warning signs - correct answer •Has the patient had any substantial weight loss? •Does the patient have signs or symptoms of depression or mood swings? •Does the patient have a preoccupation with weight, calories, and food? •Does the patient wear baggy clothes? •Does the patient have a history of excessive exercise? Anorexia Subjective and objective - correct answer Subjective: Hypotension, hypothermia, dry skin, bradycardia, edema, lanugo Amenorrhea, constipation, abdominal pain, hypothermia, lethargy or fatigue, anxious energy, headaches Objective: Leukopenia Anemia Elevated BUN Elevated LFT Hypomagnesemia Hypophosphatemia Elevated TSH Sinus Bradycardia Hypercholesterolemia Bulimia nervosa warning signs - correct answer Has the patient had any significant weight loss or gain? •Does the patient have signs or symptoms of depression? •Does the patient have a great concern for weight? •Does the patient visit the bathroom after meals? •Has the patient alluded to strict dieting/bingeing cycles? •Does the patient have marked criticism of his or her body? Bulimia nervosa Subjective and objective - correct answer Subjective Tooth enamel erosion, enlarged parotid glands, periodontal disease Irregular menses, abdominal pain, fatigue or lethargy, peripheral edema, bloating, depression Objective Hypokalemia Hyponatremia Hypochloremia Increased serum bicarbonate Elevated amylase Discuss sleep hygiene strategies for a patient complaining of insomnia. - correct answer Evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of chronic insomnia There is very little evidence to support the efficacy of other treatments (including antidepressants, antipsychotics, and antihistamines), despite their widespread use. Recommendations include: • keeping sleeping and waking times regular, • spending less than 8 hours in bed o avoid daytime napping • develop bedtime rituals that are conducive to sleep • maintaining adequate nutrition and exercise regimens, o An exercise schedule may prove beneficial, although evening exercise may be stimulating. o Avoid heavy evening meals (a light evening snack may sometimes be conducive to sleep). • avoiding sleep-altering substances such as caffeine and alcohol o Alcohol should be avoided after 5:00 p.m. o Any drugs and/or herbal supplements that may be contributory should be discontinued. All underlying causes of insomnia, such as pain, must be treated. Recommendations for appropriate sleep parameters include associating the bedroom with "sleepiness," not staying in bed for longer than 20 minutes when wakeful, and leaving the bedroom until tired, before returning Gastroenteritis - correct answer -Acute gastroenteritis is defined as diarrheal disease (three or more times per day or at least 200 g of stool per day) of rapid onset that lasts less than two weeks -cause is a pathogen; either bacterial or viral -may be accompanied by nausea, vomiting, fever, or abdominal pain -Both vomiting and diarrhea are usually present; however, either can occur alone. - Common findings on physical examination of patients with acute viral gastroenteritis include mild diffuse abdominal tenderness on palpation; the abdomen is soft, but there may be voluntary guarding. -Fever (38.3 to 38.9°C [101 to 102°F]) occurs in approximately one-half of patients Irritable bowel disease - correct answer -typical presentation is diarrhea alternating with constipation -Abdominal pain or discomfort that is consistently relieved by defecation or there has been a change in the consistency or the stool for a period of 3 months (continuously or recurring) -Defecation with varying patterns of constipation and diarrhea 25 % of the time -2 or more of the following: altered stool frequency, altered stool form (hard, loose, watery, mucoid), altered sensory act of defecation including straining, urgency, tenesmus, passage or mucous, or varied degrees of bloating and abdominal distension -This differs from the mucus occurring with colitis because there is no associated inflammatory process nor is there any blood in the stool, other than if there is an incidental finding of hemorrhoids. Differential diagnoses of the patient that presents with diarrhea - correct answer IBS, Gastroenteritis, Inflammatory Bowel Disease, Lactase Deficiency What is the difference in the mode of transmission for Hepatitis A, Hepatitis B, and Hepatitis C? - correct answer Hep A: Transmitted via fecal and oral route from contaminated food or drink Hep B: Transmitted via sexual activity (semen, vaginal secretions, and saliva), blood, blood products, organs -Vertical transmission occurs from mother to infant Hep C: Transmitted via sharing needles, blood transfusions before 1992, -mother to infant (vertical transmission), -needle-stick injuries in health care settings. -Less common, spread by sexual contact, sharing personal items (razors or toothbrushes). Treatment for Hep A, B & C - correct answer Hep A- no treatment Hep B - options : interferon, lamivudine, adefovir, entecavir, telbivudine, tenefovir Hep C : Administer antivirals such as ledipasvir-sofosbuvir (Harvoni), ribavirin, and pegylated interferon alpha-2a/2b. Use liver biopsy to stage disease Education for Hep A,B, & C - correct answer Hep A: Advise patients to avoid use of oral contraceptive pills and hormone replacement therapy to avoid cholestasis; avoid alcohol use Avoid working in food-related jobs for 1 week after onset of infection Hep B: Avoid hepatotoxic agents such as alcoholic drinks, acetaminophen, and statins (e.g., pravastatin or Pravachol Patients with chronic hepatitis or a carrier state should be instructed to practice safe sex. Hep C: Advise patient not to share razors, toothbrushes, and nail clippers and to cover cuts and sores. disease is the most common cause of liver cancer and liver transplantation in the United States. Describe the clinical presentation of appendicitis (subjective and objective findings). - correct answer Cary: Sudden pain that may start in belly button but migrate to RLQ -Nausea, vomiting -Fever/chills Liek: an acute onset of periumbilical pain that is steadily getting worse. Over a period of 12 to 24 hours, the pain starts to localize at McBurney's point. The patient has no appetite (anorexia). Classic exam findings include low-grade fever and right lower quadrant (RLQ) pain (McBurney's point) with rebound and guarding. The psoas and obturator signs are positive. When the appendix ruptures, clinical signs of acute abdomen occur, such as involuntary guarding, rebound, and a board-like abdomen. Describe the various maneuvers for diagnosing appendicitis (Rovsing's sign, Psoas sign, obturator signs, and McBurney's sign). Know what is considered a positive finding. - correct answer Psoas/Iliopsoas Positive finding if right lower quadrant (RLQ) abdominal pain occurs during maneuver. Indicates irritation to the iliopsoas group of hip flexors in the abdomen. A positive finding suggests peritoneal irritation. With patient in supine position, have patient raise right leg against the pressure of the professional's hand resistance, with patient on left side, extend the right leg from the hip Obturator Sign (Supine Position) Positive if inward rotation of the hip causes RLQ abdominal pain. Rotate right hip through full range of motion. Positive sign is pain with the movement or flexion of the hip. Rovsing's Sign (Supine Position) Deep palpation of the left lower quadrant of the abdomen results in referred pain to the RLQ, which is a positive Rovsing's sign. McBurney's Point - correct answer Area located between the superior iliac crest and umbilicus in the RLQ. Tenderness or pain is a sign of possible acute appendicitis Describe the clinical presentation for gastroesophageal reflux disease (GERD). - correct answer May have pain in epigastrium associated with heartburn, belching, coughing, hoarseness, sour taste. Symptoms may be worse AFTER eating. Symptoms associated with large and/or fatty meals that worsen when supine Objective Findings • Acidic or sour odor to breath • Reflux of sour acidic stomach contents, especially with overeating • Thinning tooth enamel (rear molars) due to increased hydrochloric acid • Chronic sore red throat (not associated with a cold) • Chronic coughing How is GERD diagnosed (know when to refer to GI)? - correct answer • Diagnosis of GERD is usually made by history alone and has a sensitivity of 80%. The severity of the symptoms does not correlate well with the severity of the disease; some patients with the most severe disease have virtually no symptoms. o GERD may also manifest with atypical symptoms such as adult-onset asthma, chronic cough, or sore throat. • When the diagnosis of GERD is unclear or when the patient fails to respond to 4 weeks of empiric therapy, the most accurate method of diagnosing the disease is by ambulatory esophageal pH monitoring • EGD is only recommended for patients with heartburn and dysphagia, bleeding, anemia, weight loss, or recurrent vomiting. • Patients with mild-to-moderate symptoms should be instructed in the appropriate lifestyle modifications and treated with antacids or OTC H2-RAs for a period of about 4 weeks. o If on the 4-week follow-up visit there is no improvement in the symptoms, the patient can be advanced to step 2 treatment for 6 weeks. o If this regimen is ineffective, the patient should be referred to a gastroenterologist. Patients who have self-medicated for a length of time may have developed erosive esophagitis or Barrett's esophagus and need aggressive treatment. • Any patient with at least a decade or more history of chronic heartburn should be referred to a gastroenterologist for an endoscopy to rule out Barrett's esophagus. o Patients with Barrett's esophagus have up to 30 times higher risk of cancer of the esophagus (adenocarcinoma type). Red flags for heartburn - correct answer **Red Flags: heartburn, dysphagia, anemia, weight loss or recurrent vomiting Discuss the patient education regarding lifestyle changes for management of GERD. - correct answer • Patients who are obese should be referred to a dietitian for counseling about weight loss. • Dietary modifications are the keystone for lifestyle change; o they include reducing the ingestion of foods that are irritating to the gastric mucosa and those that reduce LES pressure. § high-fat meals, large meals, chocolate, alcohol, peppermint, caffeine, onions, garlic, citrus, and tomatoes. o The patient should be instructed to avoid recumbency or sleeping for 3 to 4 hours after a meal and o avoid bedtime snacks. • Some medications also should be avoided because they affect the LES pressure; o these include calcium channel blockers, beta blockers, alpha adrenergic agonists, theophylline, nitrates, and some sedatives. • Factors that increase intraabdominal pressure should be avoided, such as large meals, tight or restrictive clothing, and bending or straining . • It is most helpful for patients to eat small, frequent meals, with the main meal at midday. • Eating less than 4 hours before bedtime, including snacks, should be avoided because this increases the chance of reflux. • Patients should be instructed to sleep with the head of the bed elevated, which can be accomplished by placing blocks or bricks under the legs of the head of the bed. o elevating the head of the bed 6 to 8 inches • Patients should be given assistance in smoking cessation, but the use of supplemental nicotine should be avoided because it reduces LES pressure. • Programs for stress management have not been found to be helpful in reducing the symptoms of GERD. Describe medical management of GERD. - correct answer For all patients with GERD, lifestyle modifications are the first line of treatment. If diet and lifestyle modifications are ineffective in controlling symptoms, the treatment is "stepped up" to medications For patients with to moderate symptoms but non-erosion reflux disease, the first step-up is to H2-RAs. (-tadines) • These include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid). • If there is no improvement, proton pump inhibitors (PPIs) are used in a dosage that effectively eliminates symptoms. (-prazoles) • Another alternative is to begin treatment with PPIs at higher doses and "step down" treatment to the lowest dose that effectively suppresses acid secretion. Evidence suggests that PPIs are more effective than H2-RAs in all cases of GERD. These agents should not be used in combination, especially with older adults. The PPIs should be taken 30 to 60 minutes before breakfast to maximize effectiveness. Patients on long-term therapy should have their symptoms reevaluated every 6 months in an effort to avoid potential adverse effects such as PPI-associated pneumonia, Clostridium difficile, osteoporosis, and vitamin B12 deficiency. PUD - correct answer Peptic ulcer disease (PUD) is a generic name for both gastric ulcers and duodenal ulcers. A peptic ulcer is a break in the surface mucosa of the stomach or duodenum, which results when there is disruption of the normal mucosal defenses and the tissue is exposed to the damaging effects of acid and pepsin. hallmark of PUD is a complaint of a burning or gnawing (hunger) sensation or pain (dyspepsia) in the epigastrium, which is often relieved by food or antacids Causes: Medications (NSAIDS, low dose ASA, Helicobacter pylori PUD treatment - correct answer Pharmacological therapy is the foundation of management for PUD, but nonpharmacological measures, such as smoking cessation, should be used as well. There are no firm dietary measures for patients with PUD other than instructions to avoid foods that precipitate dyspepsia. Pharmacological intervention for PUD consists of: - H2-receptor antagonists (H2-RAs), proton pump inhibitors (PPIs) *The PPIs are now the drugs of choice for treating PUD because they are more effective than H2-RAs and are easier to use omeprazole 20 to 40 mg daily or equivalent -agents that enhance the mucosal defenses, such as antacids, sucralfate (Carafate), bismuth subsalicylate (Pepto-Bismol), and prostaglandin analogs (misoprostol), -as well as antibiotics. Tests: CBC, H.Pylori Risk factors for PUD - correct answer Peptic Ulcer: Consumption of meat, fish, and a family history of peptic ulcer are risk factors for development of a peptic ulcer -PUD: H. Pylori infection, prolonged NSAID use, cigarette smoking Diagnosis criteria for IBS - correct answer According to the Rome IV criteria, IBS is defined as recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria: •Related to defecation •Associated with a change in stool frequency •Associated with a change in stool form (appearance) Treatment for IBS non pharm - correct answer Gas Producing Foods: Patients with IBS may benefit from exclusion of gas-producing foods; a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs); and in select cases, lactose and gluten avoidance Patients with IBS should be advised to exclude foods that increase flatulence (eg, beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, wheat germ, pretzels, and bagels), alcohol, and caffeine Lactose Patients with known lactose intolerance should be placed on a lactose-restricted diet. We also suggest an empiric trial of a lactose-free diet in patients who complain of persistent abdominal bloating despite exclusion of gas-producing foods. Fiber The role of fiber in patients with IBS is controversial, but given the absence of serious side effects and potential benefit, psyllium/ispaghula should be considered in patients with IBS whose predominant symptom is constipation Physical activity Physical activity should be advised in patients with IBS given a potential benefit with regard to IBS symptoms and the general health benefits of exercise Treatment for IBS pharmacological - correct answer Constipation — In patients with IBS with constipation (IBS-C) who have failed a trial of soluble fiber (eg, psyllium/ispaghula), we suggest polyethylene glycol (PEG). We initially start with 17 g of powder dissolved in 8 ounces of water once daily and titrate up or down (to a maximum of 34 g daily) to effect. We treat patients with persistent constipation despite treatment with PEG with lubiprostone, linaclotide, or plecanatide. Diarrhea — In diarrhea-prone patients with IBS, the stools are characteristically loose and frequent but of normal total daily volume. In patients with diarrhea-predominant symptoms, we use antidiarrheals (eg, loperamide) as initial treatment and use bile acid sequestrants as second-line therapy Loperamide 2 mg 45 minutes before a meal on regularly scheduled doses Eluxadolone has been approved for treatment of IBS-D Antispasmodic agents--- have been used successfully in controlling abdominal pain caused by intestinal spasm. Patients who suffer with postprandial pain not responsive to diet therapy can benefit from dicyclomine 10 to 20 mg three to four times a day by mouth or hyoscyamine 0.125 to 0.75 mg twice a day. Anticholinergics should be avoided in patients with glaucoma and benign prostatic hypertrophy because of the adverse effects and used with caution in the elderly. Tricyclic antidepressants--and selective serotonin reuptake inhibitors have been shown to relieve symptoms in some individuals. What are the risk factors are associated with Cholelithiasis? - correct answer "six Fs": fat, female, forty, flatulent, fertile, and fat intolerant What is the clinical presentation of cholecystitis? - correct answer • Most patients complain of indigestion, nausea, and vomiting, especially after consuming a meal high in fat. • Acute cholecystitis usually begins with acute, colicky-type pain. • the pain associated with acute cholecystitis persists, and as the inflammation progresses, the pain localizes over the RUQ. • Patients may complain of referred pain that radiates to the middle of the back, to the infrascapular area, or to the right shoulder. • The pain is increased by any movement, including respiration. • If the inflammation extends to the peritoneal area, the pain worsens, the abdominal muscles become rigid, and a fever is usually evident. Objective Signs: • there is often involuntary guarding of the abdominal muscles over the right side. • A positive Murphy's sign is elicited when the right subcostal region is so tender that there is painful splinting with deep inspiration or when palpation over the RUQ area causes transient inspiratory arrest • The gallbladder is palpable in fewer than 50% of the patients. • Fever is usually low grade, 99° to 101°F (38.3°C); high fever suggests sepsis. • Patients may develop mild jaundice from edema of the common bile duct. What laboratory findings would you expect to see with acute cholecystitis? - correct answer - increased WBC -Increased ALT/AST -Increased phos -increased bili -increased amylase Diagnosis & management for cholecystitis - correct answer Diagnostics: Ultrasound -gold standard for cholelithiasis HIDA scan, CT abdomen -cholecystitis Management: Diet and lifestyle changes/ surgery to remove gallbladder Assess for gallbladder syndrome post-op o Dyspepsia, nausea and vomiting, Flatulence, bloating and diarrhea. The gold standard laboratory test for diagnosis of pancreatitis (non-alcoholic) is an elevated ___and supported by a concurrent elevation of the _____ on the first day of acute symptoms. What elevated laboratory test is considered the gold standard for diagnosis of non-alcoholic pancreatitis? - correct answer Serum amylase, serum lipase. The gold standard for diagnosis is serum amylase; however, in cases in which the level is normal or mildly elevated, diagnosis can be confirmed by CT scan. What is the clinical presentation of chronic pancreatitis? (#1 cause is alcoholism) - correct answer • The patient usually presents with chronic abdominal pain, weight loss, exocrine insufficiency (malabsorption), and diabetes mellitus. (DM is present in approximately 50% of patients) • The most frequent presenting symptoms are intractable abdominal pain, weight loss, and diarrhea; but symptoms can be as mild as dyspepsia, nausea, and vomiting. • Abdominal pain is usually epigastric or in the left upper quadrant, may radiate to the back or left lumbar region, and is described as dull and constant. • The pain is often precipitated or aggravated by food or alcohol intake. What are the recommendations/guidelines for colon cancer screenings? - correct answer -50- 75 years of age (AA start at age 45). If immediate family history, will need to be checked 10 years prior to age of family member when diagnosed. Then after that, it is checked every 5-10 years. -Risk factors: Age, family history, diet high in fat, red meat, and refined carbohydrates, and low in plant fiber high risk every 3-5 years. What is the clinical presentation of diverticular disease? - correct answer Patients with diverticulosis characteristically present with: • pain in the LLQ of the abdomen. • Some patients report that the pain is worse after eating, • which may be a result of colonic distention, and that the pain is sometimes relieved with a bowel movement or passing flatus. • Elimination patterns may alternate between diarrhea and constipation, and • there may be associated abdominal distention and tenderness. • Diverticulitis may present with bleeding, which can be massive and is not associated with pain or discomfort. When the diverticula have become inflamed, there are the usual signs and symptoms of infection— • fever, chills, and tachycardia. • Patients typically present with localized pain and tenderness in the LLQ of the abdomen with • associated anorexia, nausea, and vomiting How would you manage a patient with an incidental finding of uncomplicated diverticular disease? - correct answer An incidental finding of uncomplicated diverticulosis requires no further intervention and can be managed with a high-fiber diet or daily fiber supplementation with psyllium. Know what diverticula are and be able to differentiate among diverticulosis and diverticulitis - correct answer -Diverticula are pockets that form in the lining of the colon. They can be present and simply an incidental finding (diverticulosis) or they can become infected or inflamed (diverticulitis). -Diverticulosis is just the condition where pockets in the colon are present. This is usually an incidental finding on a colonoscopy and causes no signs or symptoms. May cause mild pain after eating, usually relieved with BM or passing gas. -Diverticulitis is when these diverticula become inflamed and infected Know the risk factors and signs and symptoms of diverticulitis - correct answer -S/S: LLQ, intermittent cramping-like pain. Make have constipation OR diarrhea, fever. May feel a LLQ mass or tenderness in left iliac fossa. -Risk Factors: Having diverticulosis in conjunction with untreated constipation. Smoking, lack of exercise, obesity, NSAID and Opioid use. A patient experiencing exacerbation of symptoms of ulcerative colitis should be encouraged to eat high fiber foods such as raw fruits and vegetables. True/False - correct answer False- Dietary instruction for patients with UC is the same as that for CD Dietary concerns for patients with CD include a low residue diet when obstructive symptoms are present. Patients on a low-residue diet should avoid all foods high in fiber, including whole grain breads and cereals, all fresh fruits and vegetables, and seeds and nuts. A patient with Crohn's disease should be encouraged to eat high fiber foods such as whole grain bread, pumpkin seeds, and nuts. True/False - correct answer False Patients are allowed to have canned fruits and vegetables and should eat only white bread A person with irritable bowel syndrome (IBS) should slowly increase their fiber intake to 20-30 gm/day. True/False - correct answer True UC vs chrons - correct answer UC • Mucosal surface of colon • Friability, erosions, and bleeding • Involves rectosigmoid colon or entire colon (not small bowel) Chron's (gradual, insidious onset) • Segmental, patchy transmural inflammation bowel wall • Any portion of the GI tract • May develop fissures and abscesses In a patient that presents with gallstones, what would you expect to find in their lab studies? - correct answer -Elevated ALT and Bilirubin