Exam (elaborations) NR511 COMPLETED MIDTERM STUDY GUIDE WORKSHEET

Exam (elaborations) NR511 COMPLETED MIDTERM STUDY GUIDE WORKSHEET Risk Subjective Finding Objective Findings Diagnostics Treatment Education GI DISORDERS Appendicitis -Most common between 10-30yrs; but can occur at any age; rare in infants and older adults -men more at risk - Diets low in fiber, high in fat, refined sugars, & other carbs at increased risk. - Obstruction of appendix is cause of majority of appendicitis - contributing factors: Intra-abdominal tumors, positive family hx - Recent roundworm infection or viral GI infection -Dx made clinically, based primarily on H&P exam - Classic presentation includes acute onset of mild to severe colicky, epigastric, or periumbilical pain - Pain is vague at first then localizes within 24hrs to RLQ - Pain exacerbated by walkingcoughing - Men may feel radiated pain in testes - Abd muscle rigidity, NV, anorexia - Mildly elevated temp 99-100F common - If RLQ accompanied by shaking chills, perforation should be suspected - Older adults may present with weakness, anorexia, abd distention, mild pain leading to delayed dx and increased morbidity. -May have HTNtachy proportional to painsymptoms -When lying flat, may flex R knee to relieve tension in abd muscle -Pain with palpation in abd, diffuse in early stages. Localized to RLQ later -Positive for rebound pain; ask pt to cough to localize pain location -Sudden cessation of pain means perforation and is ER -Labs are not diagnostic and nonspecific -Women should have urine human chorionic gonadotrophin to ro ectopic pregnancy - +Rovsing’s Signdeep palpation & release in LLQ causes rebound pain in RLQ - +Psoas Sign- lift R leg against gentle pressure causes pain - +Obturator Signflex R hip & knee and slowly rotate internally causes pain - +McBurney’s Signpain with pressure applied to point between umbilicus & ilium - x-rayCT helpful when paired with positive H&P findings -Surgical; preoperative care, NPO, correction of fluidelectrolyte imbalances -Avoid narcotics -Atb with 3rd gen cephalosporin; Ex: ampicillin, gentamycin, flagyl -FU with surgeon -Ambulation after surgery -Adv diet when bowel sounds return -Return to hosp with ss of infection -Avoid heavy lifting for at least 2 wks Celiac disease ** (autoimmune disorder caused by an immunologic response to gluten) Mostly diagnosed in adulthood. A family member with celiac disease or dermatitis herpetiformis Type 1 diabetes Many asymptomatic. May complain of diarrhea, gas, dyspepsia, wt loss. Atypical symptoms: fatigue, bone or joint pain, arthritis, osteoporosis, or Muscle wasting (anemia), reduces subcutaneous fat, ataxia, & peripheral neuropathy (vitamin B12 deficiencies) osteoporosis or osteopenia (bone loss) Serologic testing for anti-tTG IgA antibody Total IgA (2% of pts have IgA deficiency and will falsely test negative) duodenal biopsies lifelong adherence to a strict gluten-free diet. Referral to a dietician to help. Some pts may need treatment with immunomodulating teaching related to gluten free diet. Some people with celiac disease have vitamin or nutrient deficiencies that do not cause them to feel ill, such as anemia due to iron NR511 Midterm Study Guide Worksheet Down syndrome or Turner syndrome Autoimmune thyroid disease Microscopic colitis (lymphocytic or collagenous colitis) Addison's disease osteopenia (bone loss) liver and biliary tract disorders (transaminitis, fatty liver, primary sclerosing cholangitis, depression or anxiety peripheral neuropathy seizures or migraines missed menstrual periods infertility or recurrent miscarriage canker sores inside the mouth dermatitis herpetiformis (itchy skin rash) hypothyroidism Pts with dermatitis herpetiformis found to have signs of celiac disease on intestinal biopsy. Test for nutritional deficiencies associated with malabsorption of C.D. (hemoglobin, iron, folate, vit B12, Calcium, and Vitamin D.) agents. deficiency or bone loss due to vitamin D deficiency. However, these deficiencies can cause problems over the long term. Untreated celiac/developing certain types of gastrointestinal cancer. This risk can be reduced by eating a gluten-free diet. Cholelithiasis is the formation of gallstones and is found in 90% of patients with cholecystitis. --Risk factors--2 types of stones (cholesterol and pigmented) a. Cholesterol (most common form): female, obesity, pregnancy, increased age, druginduced (oral contraceptives and clofibrates: cholesterol lowering agent), cystic fibrosis, rapid weight loss, spinal cord injury, Ileal disease with extensive resection, Diabetes mellitus, sickle cell anemia. b. Pigmented: hemolytic diseases, increasing age, hyperalimentation Patient complaint of indigestion, nausea, vomiting (after consuming meal high in fat), and pain in RUG or epigastrium that may radiate to the middle of the back, infrascapular area or right shoulder. Right side involuntary guarding of abdominal muscles, Positive Murphy's sign, possible palpable gallbladder, Low grade fever between 99-101 degrees. Possible jaundice from common bile duct edema and diminished bowel sounds. Mild elevation of WBC up to 15, 000 Abdominal Xray: Quick, noninvasive, reliable, and costeffective means of identifying the presence of cholelithiasis. a. Initial management-- begins with definitive diagnosis. When asymptomatic (normally an incidental finding while exploring another problem) require no further treatment except teaching s/sx of "gallbladder attack". Nonsurgical candidate can be treated with dissolution therapy or lithotripsy. Acute includes hydration (IV fluids), antibiotics, analgesics, GI rest. b. Treatment of choice for Acute cholecystitis is early surgical intervention after stabilization. Poor surgical risk may benefit from cholecystectomy operatively or percutaneously. Nonsurgical intervention: weight loss, avoidance of fatty foods to decrease attacks, alternative birth control for persons taking oral contraceptives, menopausal women taking estrogen informed about alternative sources of phytoestrogens (soy products). NR511 Midterm Study Guide Worksheet (artificial supply of nutrients, typically IV), cirrhosis, biliary stasis, chronic biliary infections. Crohn’s ** Ages 15-25 of onset and then again at 50-80. Familial tendency, smoker Carcinoma less common in patients with CD due to treatment sometimes colectomy Mild-Four or fewer loose bowel movements per day, can have small amounts of blood and mucus in the stool, and cramping in the rectum. Moderate-4-6 loose bowel movements per day containing more blood and mucus and other sx such as tachycardia, weight loss, fever, mild edema. Severefrequent bloody bowel movements (6-10), abd pain and tenderness, sx of anemia, hypovolemia, impaired nutrition. Most common sx are abd cramping/tenderness, fever, anorexia, wt loss, spasm, flatulence, RLQ pain or mass Tenderness in LLQ or across entire abd with guarding and abd distension. DRE performed to look for anal and perianal inflammation, rectal tenderness, and blood in stool. S/Sx of peritonitis and ileus may be found depending on severity of crohns. Tender mass in RLQ, anal fissure, perianal fissure, edematous pale skin tags. Extra intestinal finding may be episcleritis, erythema nodosum, nondeforming peripheral arthritis, and axial arthropathy Stool analysis to r/o bacterial, fungal, or parasitic infection for cause of diarrhea. CBC to check for anemia, eval for hypocalcemia, vit D deficiency., hypoalbuminemia, and steatorrhea. LFT to screen for primary sclerosis cholangitis, and other liver problems assoc with IBD. Check fluid and electrolytes. May have elevated WBC count and sed rate and prolonged prothrombin time. Barium upper GI series, colonoscopy, and CT to determine bowel wall thickening or abscess formation Glucocorticoids, there is no cure for CD and treatment is aimed at suppressing inflammation and symptomatic relief of complications. Initially oral prednisone 40-60 mg/d, tapered over 2-4 months, then can have daily maintenance dose of 5-10mg/d. Sulfasalazine for mild to moderate CD 500 mg BID, increased to 3-4 g/d. Clinical improvement in 3-4 wks, and then tapered to 2-3 g/d for 3-6 months, this medication interferes with folid acid absorption and patient must take supplements. Metronidazole effective in tx perianal disease and in controlling crohns colitis, other ABT’s such as Cipro, Ampicillin, and Tetracycline effective in controlling CD ileitis, and ileocolitis. Immunosuppressive meds when unresponsive to other treatments. Pt educated on disease process, diet and lifestyle changes. Stress reduction, adequate rest to decrease bowel motility and promote healing. Low residue diet when obstructive sx present such as canned fruits, vegetables and white bread Diverticulitis ** -Uncommon under 40yrs; risk rises after -Rare in pediatric; equal in menwomen -More common in -25% develop symptoms -LLQ abd pain, worsens after eating -Pain sometimes -LLQ abd tenderness with possible Firm, fixed mass may be identified in area of diverticula -Abd x-ray can reveal free air, ileus, obstruction -Barium studies show sinus tracts, fistulas, -Asymptomatic cases managed with high fiber diet or fiber supplement with psyllium -Mild symptoms managed -Increase fiber in diet to avoid constipation and straining -H2O intake of at NR511 Midterm Study Guide Worksheet developed countries -High in low fiber, high fatred meat diets -Obesity, chronic constipation, ho diverticulitis, & number of diverticula which occur in sigmoid colon. relieved with BM or flatus -BM may alternate between diarrhea constipation -May present with bleeding wo pain or discomfort -Fever, chills, tachy; LLQ with anorexia, NV -Fistula may form causing dysuria, pneumaturia, fecaluria -May have rebound tenderness with guardingrigidity -Tender rectal exam; stool usually + for occult blood obstruction -Colonoscopy to ro Ca, but less sensitive than barium for diverticula -CT with contrast outpatient with clear liquid diet and rest -Atb should not be routinely used but can be with diverticula abscess culture -Amoxicillinclavulanate K (or) flagyl with bactrim -Symptoms usually subside quickly and diet can be advanced slowly -Pain managed with antispasmotics Ex; Levsin, Bentyl, BuSpar -Avoid morphine -NG for ileus or intractable NV -Pt can be DC’d from hosp once able to maintain adequate nutrition hydration if acute phase resolved -Colon resection may be necessary if no improvement or deterioration after 72hrs of treatment least 88oz glasses to promote bowel regularity -Bulk-forming laxative may be needed Ex: psyllium, FiberCon, Metamucil GERD ** -Can occur at any age -Risk increases with age, then decreases after 69yrs -Prevalence equal across gender, ethnic, cultural -Obesity, alcohol, caffeinated beverages, chocolate, fruit, decaf coffee, fatty foods, onions, peppermint spearmint, tomato products Anticholinergics, beta- -Heartburn; mild to severe -Regurgitation, water brash, dysphagia, sour taste in AM, belching, coughing, odynophagia (painful swallow), hoarseness or wheezing at night -Substernal retrosternal pain -Worsens if reclined after eating, eating large meals, constrictive clothing -H&P usually normal -May be + for occult blood in stool -Usually Hx alone diagnoses -May manifest with atypical symptoms such as adult-onset asthma, chronic cough, chronic laryngitis, sore throat, noncardiac chest pain -If pt fails to respond to 4-8wks PPI, EGD is ordered -EGD warranted over empiric treatment when heartburn & -8wk trial of PPI; weight loss, avoiding triggers -If unresponsive to once daily dosing; can increase to twice daily; if no relief EGD needed -PPI and H2-RA should not be taken together -Pt’s on long term therapy should be re-eval’d q6mos -Weight loss, med compliance and avoidance of triggers -Small frequent meals; main meal mid-day, avoid eating 4hrs before bed, avoid straining, sleep with HOB elevated, smoking cessation, stress mgmt NR511 Midterm Study Guide Worksheet adrenergics, CaChannel blockers, diazepam, Estrogen progesterone, Nicotine, Theophylline -May present with dysphagia; dysphagia should only occur with first bite dysphagia, bleeding, anemia, weight loss, or recurrent vomiting -EGD with Barrett’s esophagus q3-5yrs Giardia Can harbor in intestine, protozoan attaches to mucosa of small bowel. In US, risk in adults is oral-anal intercourse, children in daycare. In third world countries, risk of contamination through water sources. Bloating, flatulence, nausea, watery diarrhea, weight loss, anorexia, Malabsorption Stool testing positive for trophozoites 50% of the time. Duodenal aspirate or small bowel biopsy Quinacrine Hydrochloride (Atabrine) 100 mg TID after meals for 5-7 days or Metronidazole (Flagyl) 250 mg TID for 5-7 days Teach good hand washing technique, sanitize surfaces, and avoid swimming in all types of water sources to avoid further contamination. H. Pylori Infection Risks: Increased age, living in crowded conditions, no clean water source (nonfiltered water), smoking Ache or burning pain in abdomen. Abdominal pain that is worse when stomach is empty. Nausea/loss of appetite/unintentional weight loss. Frequent burping/bloating Objective Findings RUQ/LUQ tenderness -Fecal antigen assay -Urea breath Test -Biopsy with histological examination -Serological antibody Standard triple drug therapy is clarithromycin and either amoxicillin or metronidazole with a PPI BID for 14 days. Amoxicillin preferred over metronidazole b/c there are some resistant strands of metronidazole. -Complications (PUD) -Medication side effects Irritable bowel syndrome ** Women more than men, rate 3:1; starts in late adolescence and early adulthood; rare in pts >50 -2 kinds of patientsthose with abdominal pain and altered bowel habits, and those with painless diarrhea. -Left lower quadrant pain, sharp and burning with cramping or a diffuse, dull ache, precipitated by eating, The physical exam tenderness in LLQ and over the umbilicus or epigastric area in those with small bowel involvement. Digital rectal exam may reveal tenderness and may exacerbate CBC, ESR, CMP (electrolytes, serum amylase), urinalysis, stools for occult blood, ova and parasites, and cultures. Labs mostly normal and any diagnostic clue as to the cause is Producing IBS include caffeine, legumes (and other fermentable carbohydrates), and artificial sweeteners. alleviate symptoms by eating a lower-fat diet that contains more protein. High fiber diet is good, introduced slowly to avoid Recognize triggers and avoid them. Patients must understand that the goal of treatment is to improve their symptoms, not cure the disease, and that improvement in symptoms can be NR511 Midterm Study Guide Worksheet stress and relieved with a bm or flatus. -The pain does not interfere with sleeping, frequent complaints of abdominal distention, gas, and belching, urgency to defecate, passage of large volumes of mucus within the stool. -frequently associated with psych dg, which presents in the form of anxiety, depression, and somatoform disorders (marital discord, death, or abuse) symptoms. -No weight loss or deterioration in health. -Key to diagnosis is the lack of fever, leukocytosis, or bloody stools. pg579 advanced assessment helpful. If WBC found in the stool = infectious or inflammatory process and not IBS. Rule out food intolerance, lactase deficiency (hydrogen breath test or lactose tolerance test). IBS is often confused with lactose intolerance and can be evaluated by removing lactose from the diet for 2 weeks and monitoring the symptoms. the sensation of bloating, 8 glasses of water per day, probiotic VSL#3 one packet bid, Antidiarrheal medications only temporary. -If diarrhea is severe, episodic use of loperamide (Imodium) 2 mg or diphenoxylate (Lomotil) 2.5–5.0 mg every 6 hours can be used as needed. -Constipation- lactulose or magnesium hydroxide. -Postprandial paindicyclomine 10 to 20 mg 3- 4x a day by mouth or hyoscyamine 0.125 to 0.75 mg twice a day. Anticholinergics avoid in glaucoma and bph. Tricyclic antidepressants and ssri in some pt a time-consuming process. Dietary education- fiber intake increase Peptic ulcer disease ** (includes gastric ulcers and duodenal ulcers) 3 major causes: (1) Infection w/ H.Pylori, (2) chronic ingestion of ASA and other NSAIDs, (3) acid hypersecretion such as in ZollingerEllison syndrome. Genetics, blood type, personality type, and cigarette smoking may also play a role in the development of PUD. Pts w/ COPD, cirrhosis, renal failure, and renal transplant have higher incidence. Hallmark: c/o burning or gnawing (hunger) sensation or pain (dyspepsia) in epigastrium, often relieved by food or antacids. Pts describe pain episodic pattern of c/o in which the pain tends to cluster and last for minutes, w/ episodes separated by periods of no sx. Almost half w/ NSAIDinduced ulcers are asymptomatic. Nocturnal pain: in 2/3 of pts w/ duodenal Pts w/ duodenal ulcers often demonstrate epigastric tenderness 2.5cm to right of midline, but this may also be present in cholecystitis, pancreatitis, nonulcer dyspepsia, and other GI disorders. Reports of melena or coffee-ground-like emesis usually indicate bleeding ulcer, and perforated ulcer may present w/ abdominal rigidity. Routine lab tests: normal unless significant bleeding or vomiting. Pt actively bleeding à CBC w/ diff. to eval HGB levels is paramount. Most pts w/ upper GI bleeding should have restrictive strategy, defined as transfusing when HGB levels fall below 7 g/dL. Diagnostic standard à upper GI endoscopy. Serology test or direct bacteriological analysis via an esophagogastroduode Aim to relieve pain, heal ulcer, & prevent complication and recurrences. -PPIs: drugs of choice & includes omeprazole, raveprazole, lansoprazole, esomeprazole, dexlansoprazole, pantoprazole. PPIs heal duodenal ulcers in 4 wks therapy and gastric ulcers after 8 wks. -H2-R eceptor Antagonists: Used for mild symptoms with no complication or serious Smoking cessation; avoid foods that precipitate dyspepsia. MUST follow treatment regimen. Educate about side effects such as change in stool color to black with bismuth preparations. If sucralfate with antacid, PPI, H2RA being taken, stress that sucralfate cannot be taken with other meds or NR511 Midterm Study Guide Worksheet ulcers and 1/3 of those w/ gastric ulcers. -Nausea & anorexia sometimes occur in pts w/ gastric ulcers. Vomiting and weight loss indicate more serious complications like gastric malignancy or pyloric obstruction. Pts w/ duodenal ulcers may report a reduction in pain after eating; pts w/ gastric ulcers tend to experience more intense pain after eating. noscopy (EGD) Bx à to check for H. Pylori. EGD is ordered for pts who have failed the standard triple-drug therapy for H. Pylori. A serological antibody (enzyme-linked immunosorbent assay) test can be used detect infection w/ H. Pylori, doesn’t distinguish between active or past (treated) infection and is expensive. Urease is plentiful in pts w/ H.Pylori infection. Breath tests for H. Pylori are based on the production of ammonia from the metabolism of urea by urease à indicate active infection and are noninvasive way of dx H. Pylori. In pts w/ increase in gastric acid secretion is suspected, a fasting serum gastrin level should be drawn. Levels higher than 200 pg/mL should be confirmed on repeat testing and followed by basal and peak acid-output measurements. Zollinger-Ellison syndrome should be suspected in pts disease; treatment for 2 wks. If symptoms persist past 2 weeks, EGD considered. If used for peptic ulcer tx, standard therapy is daily x 6 wks or half the dose bid x 8 weeks (cimetidine, ranitidine, nizatidine, famotidine) -Other agents: antacids were mainstay of ulcer treatment. Do not use antacids with calcium in PUD because calcium causes rebound acid secretion. Sucralfate 1g QID heals duodenal ulcers, bismuth (also has antimicrobial action against H. Pylori), misoprostol (Cytotec) used for prophylactic measure to prevent gastric ulcer formation in pts who use NSAIDs. Triple therapy for H. Pylori is a combination of 2 antibiotics (clarithromycin and either amoxicillin or metronidazole) w/ a PPI BID x 14 days. Amoxicillin preferred over metronidazole due to resistant h. pylori strains. Bismuth subsalicylate & 2 antibiotics is also effective but dosing is QID. with digoxin, ciprofloxacin, phenytoin due to it binding with these meds. NR511 Midterm Study Guide Worksheet whose fasting serum gastrin level is > 600 pg/mL and who have a basal acid output > 15 mmol/hr. Pancreatitis ACUTE CHRONIC ACUTE: About 80% of hospital admissions are a result of biliary tract disease (passing gallstones) or alcoholism. --Risk: Infection (mumps), Hyperlipidemia, Metabolic disorders (hyperparathyroidism, hypercalcemia), Drugs (furosemide, valproic acid, sulfonamides, thiazides), Endoscopic retrograde cholangiopancreatograp hy (ERCP), Abn pancreatic duct (stricture, carcinoma, pancreas divisum), Abn Common bile duct and ampullary region, Surgery of stomach and biliary tract, vascular disease (artherosclerosis, severe hypotension), trauma. CHRONIC: Slow progressive process --Risk: alcoholism, diets high in protein combined with high/low fat can further predispose to pancreatic injury from ACUTE: Pain that is intense, abrupt onset deep epigastric pain that last for hours to days. Radiates straight through the back. Pain is often refractory to narcotics. Aggravated by vigorous activity (coughing) and lying supine. Alleviated when seated and leaning forward. Intractable nausea/vomiting. Depending on severity may present with seating, weakness and anxiety. May report ingestion of alcohol or big meal before onset of symptoms. CHRONIC: Patient presents with intractable abdominal pain, weight loss, diarrhea but can be mild (dyspepsia, nausea, vomiting). Abdominal pain normally epigastric/LUQ that may radiate to back or left lumbar region that is described as dull and constant. Pain is aggravated by food or ACUTE: Severe abdominal tenderness over epigastric area accompanied by guarding. Abdominal distension presents in about 20% of patients. Bowel sounds hypoactive or absent if paralytic ileus present. Tachycardia (100-140 b/min) with rapid, shallow respirations. Increased blood pressure due to pain. Temp initially normal but increases to 100.4-102.2. CHRONIC: Mild to Moderate epigastric tenderness without rebound tenderness or guarding. ACUTE: Abdominal Pain Elevated Serum Amylase/Lipase that return to normal after 3-7 days WBC between 12-20, 000 CT of abdomen: provides fast and accurate for definitive diagnosis CHRONIC: CT and /or US of the abdomen to show abnormal size or consistency of pancreas. Evaluation of pancreatic function: Bentiromide Test--collections of normal volume and low in bicarbonate suggest chronic pancreatitis. ACUTE: Management is aimed at limiting severity of pancreatic inflammation, preventing further complications and managing symptoms. Mild symptoms can resolve on its own and managed outpatient conservatively. Fasting is necessary until symptoms have subsided. Maintain fluid status with parenteral fluids Pain medication other than opiates (to prevent pressure within sphincter of Oddi). Introduction of clear fluids implemented once pain free, amylase/lipase levels returned to normal, bowel sounds have returned, Low fat diet as patient tolerates. CHRONIC: Aimed at preventing further pancreatic damage, managing pain and supplementing exocrine and endocrine function. Sustaining from alcohol use. Relief of pain by pancreatic enzymes in some patients and others may need narcotic pain management. Operative ACUTE: Informed the cause of pancreatitis Reduction of dietary intake of fat Abstain from alcohol abuse Drug induced--avoid causing agent Hyperlipidemia-- diet instruction and information on avoidance of factors such as alcohol, estrogens. CHRONIC: Patho of disease and longterm outlook Decrease in frequency in attacks after 5-10 years Medication regimen/Rational for medications (control diarrhea and gain body weight) Pain management if long term narcotic is needed. NR511 Midterm Study Guide Worksheet alcohol, autoimmune disease, genetic mutations, hereditary predisposition, high triglycerides, severe malnutrition, tropical pancreatitis, obstruction caused by stenosis, stones, tumor, cystic fibrosis. alcohol. treatment considered in patients that fail pain management with pancreatic enzymes or analgesics. Malabsorption managed with low-fat diet and oral pancreatic enzymes (Viokase/Cotazym/Pancrea se/Creon/Donnazyme). Salmonella ** One of the major causes of diarrhea worldwide. Three species: S. typhi, S. choleraesuis, and S. enteritidis. Found primarily in chicken, eggs, and livestock, causing 85% of community-acquired Sal monella outbreaks. Individuals must ingest 10,000–1 million organisms to become infected. Duration is 2–5 days; onset is 8–48 hours after ingestion. Patients may become “chronic carriers,” defined as individuals with positive stool cultures 1 year after initial disease. Peak incidence is in summer and fall. Symptoms begin with nausea and vomiting, followed by colicky abdominal pain and bloody or mucoid diarrhea. Enteric fever results from organisms entering the bloodstream via the Present with varying degrees of nausea, vomiting, diarrhea, fever, and abdominal pain and cramping. Symptoms depend on the underlying cause but can also include fatigue, malaise, anorexia, tenesmus, and borborygmus. Individuals with profuse diarrhea may complain of rectal burning and hematochezia from rectal abrasion and bleeding. Patients may complain of symptoms that suggest dysentery, including passage of numerous smallvolume stools containing blood and mucus. Reports of voluminous stools are suggestive of a source in the small bowel or proximal colon; small stools accompanied by a sense of urgency suggest a source in the Present with varying degrees of nausea, vomiting, diarrhea, fever, and abdominal pain and cramping. Symptoms depend on the underlying cause but can also include fatigue, malaise, anorexia, tenesmus, and borborygmus. Individuals with profuse diarrhea may complain of rectal burning and hematochezia from rectal abrasion and bleeding. Patients may complain of symptoms that suggest dysentery, including passage of numerous smallvolume stools containing blood and mucus. Reports of voluminous stools are suggestive of a source in the small bowel or proximal colon; small stools accompanied by a sense of urgency The physical exam is usually normal except for the aforementioned GI problems. Depending on the degree of dehydration, the skin turgor may be poor, and mucous membranes may be dry. -Vital signs may reflect dehydration, such as a fever with an increased heart rate. Older and very young patients with gastroenteritis m ay show signs of severe dehydration such as orthostatic hypotension and dizziness. Patients who have had prolonged illness and are malnourished may present with edema resulting from hypoalbuminemia. Diagnosis is made by isolation of organism in stool. No treatment Treatment includes trimethoprimsulfamethoxazole (Bactrim DS) or a quinoline, norfloxacin 400 mg or ofloxacin 400 mg PO twice daily for 7–10 days. Stress proper handling of food, thorough cooking, and good hand washing. NR511 Midterm Study Guide Worksheet bowel lymphatics, causing bacteremia, headache, and myalgias. Tissue abscesses may develop. Stools may be foul smelling. left colon or rectum. Bloody stools suggest mucosal damage and an inflammatory process secondary to invasive pathogens. Frothy stools and flatus suggest a malabsorption problem. suggest a source in the left colon or rectum. Bloody stools suggest mucosal damage and an inflammatory process secondary to invasive pathogens. Frothy stools and flatus suggest a malabsorption problem. is necessary unless associated with fever and systemic disease. Shigella One of the most common causes of bacillary dysentery. Several species: S. sonnei is isolated in 75% of cases in the United States. Because of poor hygiene and overcrowding, it is spread via the fecal–oral route and requires only a small number of organisms to produce disease. Organism causes epithelial invasion of intestinal mucosa. Duration usually 4–7 days and is self-limiting. Incubation period of 1– 2 days after exposure or ingestion of pathogen. See Salmonella See Salmonella Diagnosis is made by isolation of organism in stool or rectal swab. In severe cases sigmoidoscopy shows mucosal hyperemia, friability, and ulceration. Initially patients present with watery diarrhea and high fever. Later colitistype symptoms develop: Abdominal cramps, tenesmus, urgency, frequent small stools with blood and mucus. Low-grade fever may persist for 2–20 days. Complications can include hemolyticuremic syndrome and colitis. Treat with Bactrim DS twice daily for 3 days if infection was acquired in the United States. Stress proper handling of food, thorough cooking, and good hand washing. Ulcerative Colitis ** Peak age of onset: 15 to 30 y/o, but may occur at any age. More common Mild: 4 or fewer loose BMs per day associated w/ Tenderness in LLQ or across the entire abdomen, often Digital Rectal Exam: to assess for anal and perianal Initial: nutrition counseling. Parenteral nutrition may be Colonoscopy should be avoided w/ NR511 Midterm Study Guide Worksheet in males. Familial tendency. abdominal cramps relieved w/ defecation, small amounts of blood and mucus in the stool, and sometimes tenesmus Moderate: 4-6 loose BMs per day w/ more blood and mucus. Systemic Sx: tachycardia, mild fever, weight loss and mild edema depending on serum albumin levels Severe: more frequent blood BMs (6-10 per day, abdominal pain and tenderness, Sx of anemia, hypovolemia, and impaired nutrition If Ulcerative Colitis (UC) confined to rectal or sigmoid area, stools can be normal or hard and dry; however, the rectum will continue to dispel mucus containing both RBCs and WBCs. As disease process moves proximally, the stools become looser. Pts may report eating less to decrease BM frequency, which leads to further nutritional deficiencies. accompanied by guarding and abdominal distention. Depending on severity: S/S of ileus and peritonitis may be found. Serological: + for antineutrophil cytoplasmic antibodies (pANCA). Fever & malaise w/ severe disease. Early disease: mucous membrane is granular, friable, and edematous w/ loss of normal vascular pattern. May be scattered areas of hemorrhage that bleed w/ minor trauma. Resulting ulcerations develop after mucosa breaks down, leaving the mucous membranes dotted w/ numerous bleeding and pusoozing ulcers. Severe disease: Copious amounts of purulent exudate. Periods of remission, sigmoidoscopy always shows some friability and granulation present inflammation, rectal tenderness, and blood in the stool. Dx made by correlating sx w/ hx and physical exam. Stool analysis and Cx are obtained to r/o bacterial, fungal, or parasitic infection (ova & parasites) as cause for diarrhea. Stool is examined for mucus and blood. Contrast radiography and endoscopy primary diagnositic tool to confirm IBD (Irritable Bowel Disease). Sigmoidoscopy, defines the actual extent of the mucosal inflammation. Bx results à chronic inflammation. Colonoscopy to determine the extent of the disease, to avoid perforation, usually reserved for pts who have started tx. necessary w/ severe anorexia or uncontrollable diarrhea. Pts w/ mild-mod diarrhea may benefit from diphenoxylate w/ atropine (Lomotil) 2.5 to 5.0 mg PO BID up to 4x daily, loperamide (Imodium) 2 mg after each BM, or codeine 15 to 30 mg PO Q4-6H. Disease limited to rectosigmoid area: topical steroids or mesalamine. Steroid enemas and foams (hydrocortisone [Cortifoam] 100 mg) nightly x 2 wks. PO formulation of Asacol (5-ASA) med help maintain remission after enemas have been d/c’d More advanced disease: Systemic glucocorticoid in combo w/ sulfasalazine or 5-ASA therapy. Glucocorticoids esp. helpful in controlling extracolonic manifestations à peripheral arthritis, ankylosing spondylitis, erythema nodosum, anterior uveitis, and pyoderma gangrenosum: Oral prednisone (Prelone), up to 40 to 60 mg in single or divided doses, tapered and not d/c’d abruptly. Severe or fulminant: (10 or > bloody stools per day): severe colitis or deep ulcerations because of risk of perforation or development of toxic megacolon. Pts should avoid caffeine, raw fruits, vegetables, and other foods high in fiber à can cause trauma to the already inflamed mucosal surface. Some pts may benefit from lactose-free diet, but not recommended unless a trial produces symptomatic relief. Bland diet high in calories and protein yet low in fat can help to control diarrhea and flatulence and maintain nutrition and weight. Antidiarrheal meds should be avoided in acute phase but can be helpful for pts w/ mild sx. All pts should be informed of disease process, tx options, and expected outcomes. Education about diet and lifestyle NR511 Midterm Study Guide Worksheet abdominal tenderness, fever, colon dilation and tachycardia à require hospitalization, monitor closely for development of toxic megacolon and colonic perforation. If no improvement after 7-10 days; consider surgical intervention. Surgery: Subtotal or total colectomy à prevent perforation of bowel and its complications. Some pts may need fluid/electrolyte management and/or blood transfusions. Most common procedure protocolectomy: Brooke ileostomy, curative and functional procedure. Immunosuppressive agents: azathioprine (Imuran), cyclosporine, and metabolit 6- mercaptopurine (6MP) à used in cases unresponsive to other medical management and in pts who are not surgical candidates. For disease unresponsive to other therapies: antitumor necrosis factor (anti-TNF) agents can be used à infliximab (Remicade) 5 mg/kg and adalimumab (Humira) administered SubQ 160 mg @ wk 1, 80 mg @ wk 2, then maintenance of 40 changes. Importance of adequate rest and stress reduction to decrease bowel motility and promote healing. Stress management techniques: guided imagery, referred for counseling if necessary. Provided information and addresses for national organizations à Crohn’s and Colitis Foundation of America: up-to-date info and local support groups. If no S/S of acute attack, they can eat whatever they want or can tolerate. About possibility of parenteral nutrition or oral supplementation during acute attacks. Foods that can cause diarrhea and gas-producing foods should be avoided during acute attacks. Female pts require special guidance and counseling before attempting pregnancy. If pregnancy occurs, NR511 Midterm Study Guide Worksheet mg Q other Wk beginning @ wk 4. Pts w/ toxic megacolon: NG tube placement for intermittent suction, NPO, antidiarrheal meds should be d/c’d. F/E imbalances need corrected: hypokalemia. Total parenteral nutrition may be necessary short term. Daily abdominal x-rays. pt must be followed closely by gastroenterologist Viral gastroenteritis ** Causes of gastroenteritis are numerous; however, bacterial, viral, and parasitic infections are among the most common. Almost all forms of enteric infection manifest with diarrhea. Several different viruses including rotavirus, norovirus, adenovirus, and astroviruses account for most cases of acute viral gastroenteritis. Most are transmitted via the fecal-oral route, including contaminated food and water. Transmission has also been shown to occur via fomites, vomitus, and possibly airborne methods. Peak viral load within the stool is anywhere between 24 to 48 hours after symptomatology. See Salmonella See Salmonella Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea, anorexia, weight loss, and dehydration. Clinical manifestations for viral gastroenteritis are due to the effects that the viruses, along with specific cytotoxins, have on the enterocytes of the intestine. The virus uses the enterocyte to replicate, leading to interference with brush border enzyme production, which in turn leads to malabsorption and osmotic diarrhea [8]. Additionally, viral toxins lead to direct damage and cell lysis of enterocytes and intestinal villa, causing a transudative loss of fluid into the intestine [15]. The Most important goal of treatment is to maintain hydration status and effectively counter fluid and electrolyte losses. Antimotility drugs are the most frequently prescribed and most effective drugs for the treatment of symptomatic gastroenteritis. These agents work by slowing intraluminal peristalsis, thereby slowing the passage of fluids through the lumen, which facilitates absorption. Patients with febrile dysentery should not receive antimotility medications because slowing the intraluminal time may prolong the duration of the disease Prevention of the spread of disease from patients with infectious diarrhea to other individuals. Teaching includes good hand washing and safe disposal of waste products. Any infant or child with infectious diarrhea should not attend day care until the diarrhea has stopped or the child has completed the prescribed course of antibiotics. Good hand washing technique is imperative to prevent household outbreaks of the disease.Patients traveling in high-risk areas should be instructed to consume only safe foods and beverages there and NR511 Midterm Study Guide Worksheet Some studies show viral shedding lasting for several weeks past symptomatology loss of cell function can lead to electrolyte abnormalities which are caused by the loss of transporter functionality. That can lead to acid-base disturbances as well. The virus is then shed through feces, and occasionally in the vomitus. Complete blood counts may reveal a mild leukocytosis in a patient with viral gastroenteritis. Other serum inflammatory markers may also show mild elevation. Patients who are suffering from significant dehydration may demonstrate hemoconcentration on complete blood count testing as well as electrolyte disturbances on chemistry panels. Dehydration may also present as acute kidney injury, evidenced by changes in the BUN and creatinine on chemistry panel. on the airplane leaving the area. HEENT DISORDERS Bacterial conjunctivitis (viral is most contagious) Occurs in fall and winter. More common in children than adults. Discharge is purulent, thick with crusted eyelids shut in the Normal visual acuity. No pupillary abnormalities. No Usually none. Consider culture of exudates for Consider fluorescein staining is corneal abrasion suspected. -Good hand hygiene and eye hygiene. -Use clean NR511 Midterm Study Guide Worksheet Direct contact with secretions or with contaminated objects and surface. morning. Sandy, gritty feeling in eye. Unilateral but usually becomes bilateral due to contamination. photophobia. Lymph nodes NOT palpable. Reddened conjunctiva (both over the eyeball and inside lid) and eyelid swelling. Hallmark symptom of bacterial conjunctivitis is purulent discharge. recurrent conjunctivitis but rarely indicated. Bacterial form is also selflimited. Treatment shortness course if initiated early. Self-limiting in 5-7 days; can delay treatment until third day -Eyedrops or ointment: trimethoprim/polymyxin B (Polytrim), erythromycin, tobramycin, gentamicin, sodium sulfacetamide, or ciprofloxacin, levofloxacin -Contact lens wearers: fluoroquinolones are first line Tobramycin (These medicines include ciprofloxacin (Cipro), gemifloxacin (Factive), levofloxacin (Levaquin), moxifloxacin (Avelox), norfloxacin (Noroxin), and ofloxacin (Floxin) Children: ointment preferred over drops One exception to the rule in regards to the effectiveness of antibiotic drops for all bacterial conjunctivitis cases is gonococcal infections. Gonococcal conjunctivitis is sight threatening because it can affect the cornea, so patients should be sent to the ER immediately. Gonococcal conjunctivitis is associated washcloth each time face is washed. -Change pillowcases daily. -Warm compresses for infectious origin. -do not wear contact lenses until inflammation resolved (1 week); discard current contact lenses. -Discard makeup used. -Symptoms should improve in 2-4 days -Instruct patients to treat the eye that is affected but to start treatment in the other eye if symptoms develop -Bacterial conjunctivitis very contagious; stay home from work or school until 24 hours of antibiotic treatment or as soon as clinical improvement (decreased redness and discharge) NR511 Midterm Study Guide Worksheet with hyper-purulent discharge Corneal abrasion Mechanical or chemical means; Trauma induced by contact lenses, damaged contact lenses, or foreign body. Spontaneous induced and often known as recurrent erosions that stems from a previous injury. More common in young, active patient. Uncommon in older adults. Excessive tearing, severe eye pain and inability to open eye due to foreign body sensation, photophobia, conjunctival hyperemia. Hx of scratching the eye, contact lens irritation, or actual trauma. Patients with recurrent corneal erosion syndrome experience searing pain in the middle of the night. It awakens them, or they feel pain on awakening -Constricted pupil, foreign body, lacrimation. Profuse tearing. -Invert eyelid to r/o foreign body underneath. Stain the eye with fluorescein and use a cobalt blue filter light or slit lamp to inspect the eye for foreign objects or scratches. Areas of epithelial disruption fluoresce green when exposed to a Wood’s lamp. Access visual acuity: should be normal unless abrasion is large. Treatment includes antibiotic eye drops or ointment for 5 – 7 days to prevent bacterial infection. Traumatic/foreign body/recurrent abrasions: Erythromycin ointment OR sulfacetamide Contact lens abrasion: ofloxacin, ciprofloxacin OR tobramycin drops/ointment Oral analgesics for pain Only ophthalmologists should prescribe topical anesthetics due to delayed wound healing and risk of ulceration, scarring, perforation and blindness Tetanus prophylaxis Normal saline to irrigate eye. Patching is not usually necessary. The patient should avoid wearing contact lenses until the abrasion heals. f/u in 24-48 hours if no improvement f/u in 24 hours to assess healing f/u by eye doctor Epiglotittis Common in young children 2-4 years; most common >7 years; may occur in older children and adults. Men > women. Infection with Haemophilus influenzae B (Hib) (most common); streptococci now major pathogen of cause. Odynophagia (pain on swallowing), dyspnea, drooling, stridor. Never use tongue blade or light due to laryngospasm and airway obstruction may occur. Transport to OR for fiberoptic laryngoscope visualization showing that epiglottis is swollen and erythematous (cherry red). Endotracheal tube should be inserted. ER care for adequate airway control. Needs hospitalization for IV antibiotics such cefuroxime (Ceftin), ceftriaxone (Rocephin), or ampicillin/sulbactam (Unasyn). Dexamethasone (Decadron) should also be administered IV and tapered as signs and symptoms resolve. NR511 Midterm Study Guide Worksheet Continuous pulse oximetry and careful monitoring of the patient’s airway are critical. Patients who develop hypoxemia and respiratory distress will require intubation. Eustachian tube disorder Some of the most common causes include conditions causing nasal congestion as is seen with allergic rhinitis, sinusitis, URIs, enlarged adenoids, and pregnancy. Additionally, those who have recently traveled in an airplane or who have been scuba-diving are at risk for ETD. Often people complain of decreased hearing or a fullness in the ears. Hearing may be muffled or diminished. May report an inability to “pop” or “clear” their ears, which normally occurs with changes of barometric pressure. They may have accompanying tinnitus or disequilibrium. Patients may come to you thinking that they have an ear infection due to pain or pressure. They may also be concerned of cerumen impaction if they are experiencing hearing loss. Physical exam findings with ETD depend on precipitating event. Nasopharyngeal examination may reveal findings consistent with allergic rhinitis, sinusitis, or URI. On the affected side, typically you will see a TM that appears retracted or “sucked back.” Diagnosis of ETD is based on the history and physical exam. If pneumatic otoscopy is performed, the affected TM will be immobile. A Weber and Rinne hearing test will reveal conductive hearing loss on the affected side. Key it to treat underlying problem. -If a cold, then nasal saline drops or a neti pot may help. -AOM and sinus infections are treated with antibiotics. -Allergic rhinitis should be treated with nasal steroids and decongestants; however, decongestants are contraindicated in children under 6 years of age. Comfort measures can include acetaminophen or ibuprofen. Patients can be instructed to attempt to relieve pressure by yawning, chewing, or sucking. Holding the nose and blowing out is not recommended due to risk of TM performation. For chronic ETD unresponsive to tx, refer to ENT. Tympanostomy tubes may be placed to equalize pressure. Hyphema (a layer of RBCs - hemorrhage) Usually a result of blunt or penetrating trauma. Vision loss and eye pain; may be Conjunctival injection noted; blood in Based on physical findings but may Possible evacuation of blood by ophthalmologist. Immediate referral to ophthalmologist. NR511 Midterm Study Guide Worksheet May be spontaneous. Spontaneous hyphema is a result of DM, iris melanoma, retinoblastoma, eye tumors, juvenile xanthogranuloma, clotting disorders, sickle cell disease or trait; anticoagulant medications. 70% of cases occur in children; peak between ages 10 and 20. Boys > girls accompanied by nausea/vomiting anterior chamber of eye, visible fluid line in pupil, photophobia, decreased visual acuity include CT, orbital ultrasonography, or US biomicroscopy. Consider hematology studies (like clotting factors) based on history and exam Eye shield; head elevated 30-40 degrees; complete bedrest and dim lighting Pain management, treat n/v; correct coagulopathy; avoid aspirin products, miotics, mydriatics in acute setting Protective eye devices. Control of diabetes and hemophilia. Med education on what to avoid at home. Meniere’s disease Age of onset 30-60; most cases develop in 50’s. Rare in young children and adults >70 years. White Americans of European descent at increased risk. Equally affects men/women. Stress, allergies; high sodium, caffeine, alcohol intake; hormonal changes; changes in barometric pressure; exposure to high noise levels for many years. Inflammatory response of inner ear from insults (blunt trauma, viral infections, allergies, reduced or negative middle ear pressure). Recurrent tinnitus, vertigo, and progressive lowfrequency hearing loss or complete hearing loss in severe cases. Acute episode last anywhere from 20min3hrs. Attacks rarely last > 4 hrs. Characterized as sudden attacks of nausea, emesis, pallor, diaphoresis, dizziness (spatial disorientation), vertigo, roaring tinnitus, increased pressure, fullness, and hearing loss in affected ear. Rapid movement aggravates symptoms, and possible report of falls or accidents No apparent abnormalities on otoscopic exam unless otitis media present. Dilation of inner ear endolymphatic system present on autopsy. Spontaneous nystagmus is observed after preventing eye fixation by having pt wear 40 diopter glasses (Frenzel Lenses). Is a diagnosis of exclusion; numerous disorders mimic this disease. Careful history, neurologic assessment, and response to empiric therapy. Weber and RInne show sensorineural hearing loss; diagnostic criteria involves 2 episodes of vertigo lasting 20 minutes along with sensorineural hearing loss and either tinnitus or a perception of aural fullness. Audiometry shows low-frequency hearing loss and impaired speech discrimintation. 1st, r/o other cause of symptoms. No proven cure; palliative tx given for reducing symptoms. Acute attacks treated with rest by closing eyes and protection from falling. Vestibular rehab reduces symptoms of unilateral peripheral vestibular dysfunction. Meds: Vestibular sedatives like prochlorperazine for severe n/v; a antihistamin