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Ulcerative Colitis
What is it
Signs and symptoms
Lab/diagnostic
Management
- Diffuse mucosal inflammation of the colon, involves the rectum and may extend upward involving the whole colon with symptomatic episodes and remission
- Bloody diarrhea is the hallmark symptom
- Stool studies are negative, sigmoidoscopy establishes diagnosis
- Management
- Mesalamine (Canasa) sup or enema for 3-12 wks
- Hydrocortisone sup and enema
- iV abx cipro and flagyl
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Mesenteric Infarct
What is it
Causes
s/s
lab/diagnostic
management
- result of inadequate blood flow through the mesenteric circulation leading to ischemia and gangrene of the bowel
- arterial or venous, coagulopathy following recent surgery
- sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings
- N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
- Lab/diagnostics
- Elevated amylase, leukocytosis, abd films, CT
- Emergent surgical intervention
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Appendicitis
Signs and symptoms
Physical findings
Lab/diagnostics
Management
- Colicky umbilical pain-pain shifts to RLQ after several hrs
- RLQ guarding with rebound tenderness,
- Psoas sign-pain with rt thigh extension
- Obturator sign- pain with internal rotation of flexed right thigh
- Positive Rovsing’s sign- RLQ pain when pressure is applied to the LLQ
- CT or U/S is diagnostic, WBC 10 to 20
- Management
- Surgical treatment, IV broad spectrum abx, IV fluids, Pain management
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Gerontology consideration with GI disorders
- Physiologic changes
- Decreased thirst and taste perception
- Decreased gastric motility with delayed emptying
- Impaired defecation signal, decreased liver size
- Possible findings and/or results- risk of
- Poor nutrition
- Altered drug absorption
- Decreased or impaired metabolism of drugs
- Dysphagia, NSAID induced ulcer
- Constipation
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Which of the following displays a current or recent Hepatitis A infection?
Antibody-specific to IgG
Anitbody-specific to IgM
Hepatitis A core Antibody
Hepatitis A Surface antigen
Anitbody-specific to IgM
Anti-HAV and IgM implies recent infection
IgG implies previous exposure and advises immunity
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Your patient is post-op cardiothoracic surgery. She develops nausea, periumbilical abdominal pain, moderate Lipase, LDH, ALT, ↓BS. What is the diagnosis?
Mesenteric Infarct
- sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings
- N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
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Crohns
What is it
Presentation
Treatment
- Mucosal inflammation and ulceration, structuring fistula development, and abscess formation
- Pt may present with a combo of the following:
- Chronic inflammation, intestinal obstruction, fistula formation, abscess formation
- Meds
- Aminosalicylates- mesalamine
- Corticosteroids
- Immunomodulatory- Tacrolimus
- Anti-TNF Monoclonal Antibodies – flagyl, Cipro
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Who is at the risk for both toxic and megacolon
Crohns and Ulcerative Colitis
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Lower UTI
Signs and symptoms
Laboratory/diagnostics
Management
- Signs and symptoms
- Dysuria, frequency, urgency, nocturia
- Laboratory/diagnostics
- U/A>10 WBC, nitrates, esterase detection
- Management
- 3 day abx therapy
- Bactrim, Cipro, augmentin
- Preganancy= amoxicillin, macrobid, Keflex
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Upper UTI
Signs and symptoms
Laboratory/diagnostics
Management
- Signs and symptoms
- Flank, low back, abd pain, fever/chills, N/V AMS
- Laboratory/diagnostics
- U/A=WBC cast, elevated ESR with pyelonephritis
- Management
- 14 day vs 6 week course of abx
- TMP/SMX; Bactrim, Cipro, augmentin, gentamicin
- Pts with suspected pyelo with N/V or more severe illness should be hospitalized
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Renal insufficiency
Symptoms/general concepts
Stages of renal failure
- Symptoms/general concepts
- Pts are often asymptomatic until the late stages of disease
- There is a direct relationship btw nephron loss and renal fx
- Systemic changes not evident until overall renal fx is <20%-25% of normal
- Stages of renal reserve
- Diminished Renal reserve: 50% nephron loss, Cr doubles
- Renal insufficiency: 75% nephron loss, mild azotemia present
- End-Stage Renal disease: 90% nephron damage, azotemia, metabolic alterations
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Renal insufficiency
Types – acute and chronic
Management
- Types
- Acute: Sudden impairment
- BUN increases out of proportion to cr
- Due to obstruction, ATN, or contrast media
- Reversible with proper therapy
- Chronic: progressive impairment over months to yrs
- Steady increase in BUN and cr (10:1 ratio)
- Intrinsic kidney damage which is irreversible but progression can be slowed
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Management for Renal insufficiency
- Acute renal insufficiency
- Determine cause and intervene to prevent permanent kidney damage
- Chronic renal failure
- Institute mechanism to slow the progression of the renal failure
- Controlling HTN and DM
- Reducing dietary protein intake to 40g/day
- Modifying the dosage of medication
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Causes of Acute renal failure
- Pre renal (outside kidney)
- Caused by conditions that impair renal perfusion-
- Shock, dehydration, cardiac failure, burns, diarrhea, vasodilation/sepsis
- No damage to renal tubules
- Intrarenal (renal or intrinsic)
- Disorders that directly affect the renal cortex or medulla
- Allergic disorders, obstruction of renal vessels, nephrotoxic agents, mismatched blood transfusions
- Post renal
- Results from urine flow obstruction
- Mechanical- calculi, tumors, urethral strictures, BPH
- Functional- neurogenic bladder, diabetic neuropathy
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What is the criteria for Dialysis?
A- acidosis
E- electrolyte disarray
I- Intoxicants
O- Fluid overload
U- uremic symptoms (Nausea, seizure, pericarditis, bleeding)
Do dialysis early – Keep BUN <100 Cr <10
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What is the management for acute renal failure?
- Prerenal:
- Expand intravascular volume, consider dopamine
- Intrarenal:
- Maintain renal perfusion, stop nephrotoxic drugs, renal replacement therapies as indicated
- Postrenal:
- Remove source of obstruction, check Foley, CT, renal ultrasound
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Renal Calculi: Nephrolithiasis
Signs and symptoms
Laboratory/diagnostics
Management
- Signs and symptoms
- Frequency/urgency, Pain, bleeding, colic like flank pain, radiating pain to groin indicates the the stone has passed to the lower third of the ureter
- Lab/diagnostics
- Serum urine= elevated minerals responsible for stone formation (calcium, uric acid, creatinine, oxalate)
- Abd X-ray, CT should be performed
- Management
- Depends on stone type, location, extent of obstruction, fx of kidneys
- Analgesia and hydration – morphine, toradol, reglan
- If stone is obstructing outflow or accompanied by infection, removal is indicated
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Benign Prostatic Hypertrophy
Signs and symptoms
Laboratory/diagnostics
Management
- Signs and symptoms
- Frequency, dysuria, urgency, nocturia, incontinence, hesitancy dribbling retention
- Laboratory/diagnostic
- U/A to detect infection, PSA>4, transrectal US if there is a palpable nodule or elevated PSA
- Management
- Consult urologist, Alpha blocker-flomax,
- 5-alpha reductase inhibitor- proscar to shrink prostate
- TURP if urinary symptoms persist
- Avoid meds the worsen signs/symptoms of BPH
- Benadryl, Sudafed, afrin, SSRIs, diuretics, narcotic
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Gonorrhea
Signs and symptoms
Lab/diagnostic
Treatment
- Signs/symptoms
- Females often asymptomatic (80%), dysuria, urinary frequency, green vaginal discharge, White/yellow-green penile discharge
- Lab
- Fram stain of discharge smear shows gram negative dipliococci and WBC
- Treatment-
- Rocephin 250 IM X1 dose to tx gonorrhea +
- Zithromax 1 g orally X1 to cover chlamydia
- Report to health department
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Syphilis
Clinical stages
- Stages
- Primary- painless ulcer, located at site of exposure
- Secondary- flu-like symptoms, arthralgia, lymphadenopathy
- Latent- seropositive, but asymptomatic
- Tertiary- cardiac insufficiency, meningitis, aortic aneurysm, hemiplegia, hemiparesis
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Management of syphilis
- Treatment
- Primary, secondary or early syphilis less than 1 yr
- PCN G 2.4 IM
- Late, latent and inderminate length; tertiary stage
- PCN G 2.4 IM weekly X3
- PCN allergy
- Doxycycline 100mg PO twice a day
- Erythromycin 500mg PO 4 Xday
- Report to health department
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What is the confirmatory test for diagnosing syphilis?
Fluorescent treponemal antibody absorption (FTA-ABS)
Syphillis: STD caused by multiple organs and by treponema pallidum, a spirochete. Third most common reported infectious disease in the US.
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When treating a pt diagnosed with syphilis, what drug allergy is most important to consider before initiating Tx?
PCN allergy, syphilis is treated with PCN G
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Chlamydia
Signs and symptoms
Lab/diagnostic
Treatment
- Signs/symptoms
- Often asymptomatic, dysuria, thick cloudy penile discharge, painful intercourse
- Lab/diagnostic
- Chlamydia culture is most definitive test
- Treatment
- Azithromycin 1 g PO X1 dose or
- Doxycycline 100 PO twice a day X7 days
- Report to health department
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Vulvovginitis
Signs/ symptoms of trich, BV, candidiasis and treatment
- Trichomonas- frothy yellowish-green discharge, pruritus, strawberry patches on cervix and vagina
- Flagyl 2 g PO single dose; 500mg PO bid x7 days
- Bacterial vaginosis- fishy smelling discharge, vaginal spotting
- Flagyl 2g PO single dose; 500mg PO Bid x7days; gel 0.75%, 5g intravaginally BID X5 days
- Clindamycin vaginal cream 2% 5g intravaginally at bedtime X7days; 300mg PO BID X7days
- Candidiasis-thick white, crud like discharge
- Monostate 1% 5g intravaginally at bedtime X7days
- Terconazole 80mg suppositoru at bedtime X3days
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What are the lab/diagnostics for prerenal disease, Inrarenal disease and post renal disease?
Serum BUN
Urine Sodium
Specific Gravity
Urinary sediment
Fractional excretion of Sodium (FEna)
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What is the normal value of?
HgB
Hct
TIBC
Serum Iron
MCV
MCH
MCHC
- Hgb = 14-18 (males) 12-16 (female)
- Hct = 40-54% (males) 37-47% (females)
- TIBC = 250-450
- Serum Iron = 50-150
- MCV = volume/size – 80-100
- MCH = amt/wt – 26-36%
- MCHC = consentration/color – 32-36%
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What are the characteristics and values of MCV?
What are the characteristics and values of MCHC?
- Microcytic= <80
- Normocytic= 80-100
- Macrocytic= >100
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- Hypochromic <32%
- Normochromic 32-36%
- Hyperchromic >36%
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What are the differential diagnosis for Low MCV?
What are the differential diagnosis for high MCV?
What are the differential diagnosis for normocytic?
Microcytic- Iron deficiency anemia and thalassemia
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- Macrocytic- B12 or folate deficiency, alcoholism, liver failure, and drug effects
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- Anemia or chronic disease, sickle cell disease, renal failure, blood loss, and hemolysis
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Iron deficiency Anemia
Signs and symptoms
Lab/diagnostic
Management
- Symptoms
- As the Hct falls- Pica, dyspnea and mild fatigue with exercise, spoon shaped nails
- Lab
- Low hgb, hct, MCV, MCHC, RBC, serum iron, serum fr
- High TIBC, RDW
- Management
- Oral ferrous sulfate 300-325mg 1-2hrs after meals
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Thalassemia
What is it
Lab/diagnostic
Management
- Genetically inherited disorders resulting in abnormal Hgb production and microcytic, hypochromic anemia
- Lab/diagnostic
- Low hgb, MCV, MCHC,
- Normal TIBC and ferritin
- Management
- No tx for mild to moderate, transfusion or splenectomy for severe
- Iron is contraindicated as iron overload can result
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Folic Acid Deficiency
Signs and symptoms
Lab/diagnostics
Management
- Signs and symptoms
- Fatigue, dyspnea on exertion, HA, Glossitis,
- Laboratory/diagnostics
- Low Hct, RBC, serum folate
- Elevated MCV
- Normal MCHC
- Management
- Folate 1mg PO Q day
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Pernicious Anemia
Signs and symptoms
Lab/diagnostics
Management
- Signs and symptoms
- Neuro like symptoms
- Lab/diagnostics
- Low Hgb, Hct, RBC, serum B12
- Increased MCV
- Management
- B12 (cyanocobalamin) 100mcg IM daily X1week
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Anemia of chronic disease
Signs/symptoms
Lab/diagnostics
Management
- Signs/symptoms
- Fatigue, weakness, dyspnea on exertion, anorexia
- Lab/diagnostics
- Low Hgb, serum iron, TIBC
- High serum ferritin
- Normal MCV and MCHC
- Management
- Treat associated disease, provide nutritional support
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Leukemia
Signs/symptoms
Lab/diagnostics
Management
- Signs and symptoms
- May be asymptomatic, weight loss, fatigue
- Lab/diagnostics
- Elevated ESR, bone marrow aspiration is required to confirm the diagnosis
- Management
- Chemo, bone marrow transplant, control symptoms
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Classifications of leukemia
- Acute Nonlymphocytic Leukemia/Acute Myelogenous Leukemia
- Constitutes 80% of acute leukemia in adults
- Acute Lymphocytic Leukemia (ALL)
- 90% remission in children, pancytopenia with circulating blast (hallmark of disease)
- Chronic Lymphocytic Leukemia (CLL)
- Most common in adults
- Lymphocytosis (hallmark disease)
- Chronic Myelogenous (CML)
- Philadelphia chromosome seen in leukemic cells (hallmark of disease)
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Lymphoma
Diagnosis/staging
- Stage 1
- Disease localized to single lymph node or group
- Stage 2
- More than 1 lymph node group involved; confined to one side of the diaphragm
- Stage 3
- Lymph nodes or spleen involved; occurs on both sides of the diaphragm
- Stage 4
- Liver or bone marrow involvement
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What are the types of Lymphoma?
- Non hodgkins lymphoma
- Cause is unknown, may have viral etiology
- Often presents with lymphadenopathy
- Most common neoplasm btw 20-40 yrs
- Hodgkins disease
- Cause is unknown
- More common in males; avg age is 32 yrs
- Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease
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Idiopathic thrombocytopenia Purpura
Lab/diagnostic
Management
Other consideration
- Lab/diagnostic
- Bone marrow analysis
- Management
- <20,000
- high dose corticosteroids may elevate within 2-3 days
- IV gamma globin 2-3 days, plt transfusion
- Other consideration
- Thrombocytopenic precaution
- Heparin induced thrombocytopenia purpura HIT
- Argatroban, Lepirudin
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Disseminated Intravascular Coagulation (DIC)
Associated conditions
Signs and symptoms
Lab/diagnostics
- Associated conditions
- Infection/sepsis, liver disease, massive trauma, extensive burns, shock, obstetrical complications, leukemia
- Signs and symptoms
- Bleeding vs thrombosis
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Lab/diagnostics for DIC
- Increase PT/PTT/FDP and low fibrinogen/plt
- Thrombocytopenia (pls <150,000)
- Hyperfibrinogenemia (fibrinogen <170)
- Increased fibrin degradation product FDP (>45 or >present at >1:100)
- Prolonged PT >19sec
- Prolonged PTT >42sec
- increased FDPs give a predictive accuracy of 96% for diagnosing DIC
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Management of DIC
- Goal- treat underlying condition and control bleeding
- transfusion for severe bleeding
- Platelets (for thrombocytopenia),
- FFP (to replace clotting factors) and
- cryo (to maintain fibrinogen levels)
- overall therapy is aimed at cessation of bleeding, increasing plasma fibrinogen and the platelet count, and decreasing FDRs
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Which of the following is not an indicator of prerenal failure?
BUN/Cr ratio > 10:1
FeNa < 1
Specific Gravity > 1.015
Urine Na > 40
Urine Na > 40 (this is postrenal)
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53 yo M c/o dribbling and nocturia. You suspect BPH. PSA is 3.2. What confirms the dx?
- Transrectal ultrasound
- Laboratory/diagnostic
- U/A to detect infection, PSA>4, transrectal US if there is a palpable nodule or elevated PSA
- Management
- Consult urologist, Alpha blocker-flomax,
- 5-alpha reductase inhibitor- proscar to shrink prostate
- TURP if urinary symptoms persist
- Avoid meds the worsen signs/symptoms of BPH
Benadryl, Sudafed, afrin, SSRIs, diuretics, narcotic
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Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure?
Call surgery and arrange for an exploratory laparotomy & pelvic abscess drainage (key is rigid abdomen)
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What is azotemia?
Azotemia – an excess of nitrogenous waste products in the blood- high levels of uria
BUN>100= tx dialysis
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What should the dietary protein requirement be with chronic renal insufficiency?
<40g/day
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Which lab value is expected in iron deficiency anemia?
Elevated MCHC
Elevated TIBC (>450)
Elevated MCV
None of the above
Elevated TIBC (>450)
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Your patient is a 30 Greek F with microcytic anemia who has just returned from the middle east. What lab is not expected in her anemia?
Low serum ferritin (<15)
Low Hgb
TIBC 300
MCHC < 32%
Low serum ferritin (<15)
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