PCM exam III flashcards.txt

It is normal to go 3 times per week or 3 times per day or anything in between

Fiber, fluid and fun

• analgesics and anticholinergics
• antihistamines, antispasmodics, antidepressants, antipsychotics
• Cation containting supplements: iron, calcium, aluminum
• neurally active agents: opioids antihypertensives

Weakness in the tissue that holds the bowel in place and the bowel falls down behind the uterus and into the vagina

Straining, manual labor, child birth

Rectum that pushes the wall of the vagina, pelvic floor dysfunction

• Over 50
• unexplained weight loss
• anemia
• evidence of GIB
• perisistent or progressive pain
• FH colon cancer
• fasting nocturnal or large volume diarrhea

• wt loss
• low grade fever
• night sweats

Neurologic disorder impairing sphincter function

Dyssynergic defication, rectal prolapse

Have female patient strain with the examining finger oriented anteriorly

obstruction, megarectum, megacolon, hirshsprungs disease

loss of normal colonic relfexes and sensation

colon that is dialated and the patient is unable to move through the colon, thus they are dependent on more and more laxitives for defecation

• in coordination of contraction of colonic and rectal muscles and internal and external sphincters
• leads to attempts to defecate against closed anal sphincters
• with or without difficulty deficating strain even with soft stools
• on examination they are inable to voluntarily relax the external sphincters on request

• Lifelong constipation
• occasional passage of an enormous formed stool
• causes are congenital (hirschsprung disease) or aquired defects in the intrinsic innervation of the colon

IBS, slow colonic transit, pelvic floor dysfunction

Parkinson's, MS, colon surgery, spinal cord injury, diabetes mellitus, pseudo-obstruction

• urinary obstruction/infection
• spontaneous perforation
• stercolar ulcer � ischemia on bowel wall
• fecaliths- appendix

Prokinetics, lubricating agents, routine enemas

• stool softeners/ bulking agents
• osmotic agents
• stimulating agents

• fiber fluids fun
• D/C or change offending meds if possible
• bowel retraining
• educations and reassurance

WATER

Lower stool surface tension and soften so that more water enters more easily not as good as laxatives

• Non-absorbable agents to promote fluid shift
• intestinal water secretion increases
• increases stool frequency

PEG, Lactulose, Saline

Alter electrolyte transit at mucosa and increase motor activity

• Large mass of bulky dry hard stool in the rectum secondary to chronic constipation
• watery stool may form higher in the bowel and leak around the impaction causing soiling or diarrhea

• dilitation- toxic megacolon
• rectal tears
• rectal tissue necrosis

• Urge to deficate without ability to have a BM
• abdominal pain
• bloated or hard abdomen
• anorexia
• nausea and vomiting
• rectal discomfort
• generally ill feeling
• confusion
• leakage of wet stool or thin/pencil stool

Patients who are myelosuppressed or have altered bleeding times

• anorectal manometry
• defecography
• pelvic floor electromyography
• anal endosonography

• Chron's disease
• ulcerative colitis
• syphillis
• TB
• leukemia
• cancer
• HIV

Acute and chronic anal fissures

Anal fissure

blood on toilet paper or stool

• can ulcerate with internal sphincter fibers seen at base
• may develop sentinel pile or sentinel tag
• may require surgery

external

pregnancy, obesity, chronic diarrhea, loss of muscle tone, chronic constipation, portal hypertension, professions with lots of sitting

dont prolapse

prolapse through anus on straining but spontaneous reduction

Prolapse and may require manual/digital reduction

Cannot be reduced just hang out all the time

• rubber band ligation
• infrared coagulation
• bipolar diathermy
• laser photocoagulation
• sclerotherapy
• cryotherapy

fiber

analgesic creams hydrocortisone suppositories sitz baths

acute may require surgical intervention if significant symptoms

Family of disorders that produce symptoms of cerebral hypoperfusion in response to postural challenge; they involve the dysfunction or disregulation of postural reflexes

• Orthostatic hypotension
• delayed orthostasis
• postural orthostatic tachycardia syndrome
• neurally mediated hypotension (vasovagal reflex or reflex syncope)

• Dizziness or lightheadedness
• Visual blurring
• Darkening of visual fields
• Generalized weakness
• Loss of conciousness

• SBP>20 mmHg
• DBP>10 mmHg

• Autonomic insufficiency
• Volume depletion

• antihypertensive agents
• tricyclic agents
• monoamine oxidase inhibitors
• dopamine agonists

• Adrenocortical deficiency
• Pheochromocytoma

• Parkinson's disease
• multisystem failure
• CNS tumor
• Myelopathy
• Dementia/multi-infarct

• Orthostatic precautions � pause at the side of the bed
• Small, frequent, low carbohydrate meals- increased shunt to internal organs with large meals or meals heavy on carbs which are vasodilitory
• Avoid alcohol- vasodilitor and diuretic

Compressive stockings

• Leg crossing
• isometric hand gripping
• respiratory manuvers pursed lip or sniff
• Exercise
• Elevate the head of the bed at night (activates the RAS reducing nocturnal diuresis)

Increase sodium in diet

Erythropoietin- use in anemic patients less than 35% aim for normal hct

Inihibits vasodilating effects of adenosine and increases sympathetic tone

• Florinef
• Midodrine
• NSAIDs
• Caffeine
• Erythropoietin

Midodrine (also dose while pt is awake)

Prostacyclin inhibition, vasoconstrictor and activation of RAS

Indomethacin

BP effects of therapy are posture independent so when the patient moves to sitting or laying position their BP jumps to hypertensive state

90mmHG and 180 mmHG

Nocturnal nitrates

Delayed Orthostasis

10-45 mins

True

POTS

14-45 years old

Postural orthostatic tachycardia syndrome

Women

• Reduction in effective circulating blood volume (ECBV) � (peripheral venous sympathetic denervatino with preserved cardiac innervation, dynamic orthostatic hypovolemia)
• Acutal reduction in effective circulating blood volume- (possible renal sympathetic denervation decreased activation of RAAS, reduction in red cell mass)
• Parasympathetic insufficency leading to attenuated baroreceptor responses
• Primary sympathetic excess

racing heart, palpitations, anxiety, tremulousness, irritability, difficulty concentrating, difficulty focusing, sleeplessness, headache, lightheaded, fatigue, SOB, Exercise intolerance, nausea, bloating, abdominal cramping, constipation, diarrhea, cutaneous mottleing, dependent rubor, cold intolerance, heat intolerance, hear fainting, fainting, sweats, good days, bad days (I'm having a bad day b/c of this exam)

anxiety disorders, ADHD, depression, somatization, deconditioning

• anxiety, fight of flight hyperactivity, overfocused concentration, mimicking ADHD, Inability to shut down at night or sleeplessness
• Gastrointestinal dysmotility, Raynaud's symptomatology, cutaneous vasomotor abnormalities

• Postural
• fatigue
• headache
• lightheadedness

Exertional fatigue and breathlessness

• Postural neurocardiogenic symptoms
• nausea
• diaphoresis
• pallor
• profound episodic fatigue

• patients feel miserable
• misunderstood
• often ridiculed
• depondent about normal functioning

30 point orthostatic rise in heart rate or maximum orthostatic heart rate >120/min and less than 10 mmHg drop in SBP

• bedside postural vital signs
• tilt table testing
• holter monitor

130-150

idiopathic

Mitochondrial disease

• High sodium diet
• Florinef
• Midodrine
• NSAIDs
• periodic saline infusion
• Beta blockers
• Clonadine
• SSRIs
• Erythropoeitin

Beta blockers

• Hydrophilic agents to minimize risk of fatigue
• Nadolol
• Bisprolol
• Atenolol
• Metoprolol

• Clonidine
• very helpful for insomnia, reduces supine BP but not upright BP
• Beta blockers before bed

Serotonergic pathoways appear to mediate between vagal afferens and sympathetic efferents

• Erythropoietin
• continuous saline infusion

Pyridostigmine- therapy is limited by gastrointestinal hypermotility symptoms

• High sodium diet
• florinef
• midodrine
• indomethacin

• Hypovolemic
• Cardiogenic
• Distributive

Increase

decrease in CO with evidence of insufficient tissue perfusion in the presence of adequate intravascular volume

• Sustained hypotension (SBP < 90 mmHg for >30min)
• Increased LV filling (PCWP >15mmHg)
• Reduced systolic cardiac function

• Severe LV dysfunction
• Extensive RV infarction
• Mechanical complications
• acute mitral regurgitation
• VSD
• Free wall rupture
• Conduction abnormalities

Myocarditis, end stage cardiomyopathy, myocardial contusion, LVOT obstruction, Obstructive tumor, septic shock with myocardial depression, pulmonary embolism, aortic dissection with acute AR or tamponade, stress cardiomyopathy (broken heart syndrome)

7 hours

• Elderly age 70 and up
• diabetes
• anterior infarction
• prior MI
• 3 vessel left main disease
• early use of beta blockers in large infarcts (can cause hypotension that may lead to shock)

• Rx- pressors and inotropes
• temporary pacing
• Intra-aortic balloon pump (IABP)
• Fibrinolytics
• Revascularization: CABG/PCI
• Ventricular assist devices (VADs)
• Cardiac tranplantation

vasoconstriction and inotropic stimulant

• at low doses � renal vascular dialation
• at medium doses- chronotropic/inotropic (beta)
• at high doses- vasoconstriction (alpha)

positive inotrope, vasodilates- decreases afterload so hard to give to a shock patient

• temporary balloon that is inserted through the aorta into the arch and is programmed to inflate during diastole which fills the coronary arteries and deflate during systole to decrease afterload
• Systole: decreases afterload, decreases cardiac work, decreases myocardial oxygen consumption, increases cardiac output
• Diastole: aucmentation of diastolic pressure, increases coronary perfusion

• Percutaneous coronary interventions
• is a stent in the coronary artery establishing patency

• Coronary Artery bipass graft
• uses the internal mammary artery or saphenous vein to bypass coronary circulation and feed the heart

Pump that runs from the ventricle to the aorta

LV failure

Left ventricular assist device, pump that vaccumes out blood from the ventricle into the aorta

Post infarction ventricular septal defect

• uncommon, mostly due to a posterobasal septum or ami apical septum, ECHO best diagnostic test
• IABP, dobutamine for acute stabilization100% mortality without surgery only 87% with surgery closure device

Acute Mitral regurgitation

immediate repair or replacement with or without CABG ASAP surgical delay increases mortality

• majority require mechanical ventilation
• IABP, nitroprusside, dobutamine, LVAD, emergent coronary angiography

• RV infarction
• pulmonary embolism
• Cardiac tamponade
• constrictive pericarditis

• Fluids to achieve PCWP of 15-18 mmHG
• Dobutamine
• IABP
• Revascularization improve in hospital M and M
• pRVAD

• RV infarction
• pulmonary embolism
• tamponade
• constrictive pericarditis

Acute mitral regurgitation

VSD

Not a true hernia, represents a weakened abdominal fascia, usually happens post pregnancy or with obesity

Diastasis Recti

The abdominal muscles bow outward because of abdominal girth

Reduce obesity and PT for abdominal muscle strengthening

Intergluteal cyst, abscess or sinus tract of the upper part of the natal cleft

Men

35 to 45 rare over 45yo

Can form absess and follow sinus tract to form bigger abcess

Pilonidal disease

• Sudden onset of severe pain and swelling
• acutely inflamed mass noted overlying the sacrum or coccyx
• fever is unusual unless cellulitis is present
• may occur following trauma

persistent drainage from the sinus connected to the cyst 1 or more sinus openings with drainage of mucoid or purulent fluid

• Sitz baths/donuts
• surgical treatments- I and D if acute
• Surgical excision cysts and tracts = definitive treatment with primary or secondary closure
• Antibiotic to cover skin flora if exacerbated- no indication for long term use
• can recur Prevention is shaving hair of gluteal area

Diveriticular disease

Where blood vessels penetrate the colon

Sigmoid colon

silent disease where patient has diveraticula but they don't cause a problem they are silent

when those diverticuli get infected or perforate or abscess or become inflammed

sac like protrusion of the colonic wall

• Diverticulitis
• abscess
• PERITONITIS
• fistula formation- openings to bladder or vagina
• bleeding

• often asymptomatic
• crampy LLQ pain
• alternating diarrhea constipation
• with or without fever
• can develop lower gi bleed

• none if asymptomatic
• occult blood and stool leukocytes
• abdominal plain film free air for perforation
• CT of abdomen- if they don't respond to treatments
• Other- barium enema but only if not acute b/c you risk perfing their colon same with colonoscopy

• Perforation- secondary to incresed intraluminal pressure insipissated food particles or inflammation necrosis and infection
• Peritonitis- purulent or fecal
• abscess or fistula- can cause communication
• stricture- from scarring predisposition to obstruction

• Prevention: high fiber diet, exercise, adequate liquids
• Treatment: bowel rest, antibiotics if diverticulitis, surgical repair of any damage
• Other strategies: treat constipation, increase exercise, increase fiber

Familial polyposis syndrome

• generally asymptomatic
• constipation, flatulence, rectal bleeding

Colonoscopy, Occult blood test, biopsy of the polyp

hyperplastic and inflammatory

adenoma and adenomatous polyps

• Pts over 50 y.o.
• Diet rich in red and processed meats
• inflammatory bowel disease
• inherited disorders (FAP, hereditary non-polyposis colon cancer)
• Obesity
• Smoker
• Heavy EtOH
• Diabetes

epigastric, incisional, umbilical, direct inguinal, indirect inguinal, femoral

epigastric, umbilical, incisional

In the anterior abdominal wall

Area between the breastbone to the umbilicus

Congenital

Midline incisions

upper incisions

Verticle

tension, technique, infection

False recurrence rate after surgical repair is 25-50%

Direct inguinal hernia

Direct inguinal hernia

Indirect inguinal hernia

Indirect inguinal hernia

Femoral

Inguinal hernia

Femoral hernia

• Female especially older
• prior childbirth
• muscle weakness
• prior inguinal repair

• asymptomatic
• heaviness or dull sense of discomfort
• worsens with strainign lifting end of day or with prolonged standing
• manual/physically active professions are aware before more sedentary workers
• incarceration and strangulation
• pain in area of hernia

Unilateral pain in the groin without demonatrated hernia

Men

Leaning forward and bending (hockey, soccer, rugby, football)

• repetitive strain in the inguinal area
• tear external oblique with illioinguinal nerve injury
• osteitis pubis
• myotendinous strain- adductor rectus

Sports hernia

• Osteitis pubis is possible so bone scan
• MRI/US- occult hernias

Rest, NSAIDs, Ice packs, surgical consult if it fails conservative exploratory and repair

occurs when the antemesenteric wall of the intestine protrudes through a defect in the abdominal wall. If such a herniation becomes necrotic and is subsequently reduced during hernia repair, perforation and peritonitis may result. A Richter's hernia can result in strangulation and necrosis in the absence of intestinal obstruction. It is a relatively rare but dangerous type of hernia.

• �Lateral Ventral hernia�
• developse through the spigelian fascia
• occurs between the muscles found in the abdominal wall
• Linea semilunaris on each side of the rectus abdominus
• osften little outward evicence of swelling so may go undetected longer
• occur in men and women equally

<18.5

18.5-24.9

25-29.9

>/= 30

Weight in pounds/ heigh in inches squared X703

CV and DM2

>35 inches

>40 inches

200

100

60

Fruits and veggies should take up the majority with grains an protein making up a smaller portion

• weight
• weight changes
• dysphagia
• food intolerance
• reflux
• abnormal lab values

Thickened liquids, mechanical soft grount and pureed food

Sodium, potassium, phosphorus and fluid and protein

2 gm sodium, fluid restrictions

Avoid foods with high potassium levels

• Thin
• nectar thick
• Honeylike
• spoon thick

• regular liquids, no adjustment needed
• buttermilk, tomatoe juice

falls slowly from a spoon can sip through a straw

• drops from a spoon too thick to sip from a straw
• Example: tomato sauce

• Maintains shape needs spoon too thick to drink
• pudding

• Pureed
• bread- pureed or pre gelled, slurry
• fruits- pureed/well mashed no seeds etc
• Veggies pureed

• Describe a dysphagia diet level 2
• mechanically altered
• soft testured so can form a bolus
• beverages have suspended pulp, bits of texture
• moist well cooked veggies cut in half

• advanced
• near normal texture
• exclude crunchy sticky or very hard foods
• moist breads, cereals, desserts potatoes soups

Edema, HTN, CHF, Renal impairment

Renal failure

beta blockers, potassium supplements, ACE/ARBs

green beans, iceburg lettuce, 1 egg, one small banana, one orange, potatoe with skin

<200 mg/qd

• Meat
• Whole milk/butter/cream

• Trans fat
• cholesterol
• sodium
• fat all types

margarine, shortening, fried foods, packaged foods made with hydrogenated oils, french fries, doughnuts, baked goods including pastries and pie crust, biscuits, pizza dough, cookies and crackers

• Omega-3 fats
• Dietary fiber

Salmon, tuna, mackerel, sardines, walnuts, canola, soybean, flaxseed oil or ground

• 20-30 grams per day
• fruits, veggies, whole grains, dried beans
• 5 cups of fruit/veggie or 3 ounces of whole grain foods

• heart failure
• hypertension
• renal disease
• conditions of fluid retention or swelling

2000

Sodium, Potassium, protein, phosphorus, calcium

Inability to digest sugar found in dairy

lactase deficiency

white

bloating, flatus, diarrhea, cramps, delayed growth in children

30 mins to 2 hours

Bacterial overgrowth, infectious enteritis, giardiasis, mucosal injury (celiac, IBC, Drug and radiation induced)

Test for the presence of hydrogen after lactose load (urea breath test)

• avoid milk products
• alternatives: yogurt, buttermilk, aged cheese, ingest lactase

Liver, fish oils, fortified milk, eggs

Elderly, achoholism, liver disease, night blindness, dry skin

skin disorders, hair loss, poss teratogenic

citrus fruits, strawberries, broccoli, mixed green veggies

neurotransmitter synthesis, collagen synthesis

elderly men, alcholism, college students and sailors

Poor wound healing, bleeding gums, petechiae, scurvey

Diarrhea

Fortified milk

calcium regulation, cell differentiation

Elderly, those with low sun exposure

Osteomalacia, ricketts

hypercalcemia, renal calcuil, soft tissue calcium deposits

spinach, broccoli, asparagus

• Poppy the sailor man!
• Because he is a sailor traditionally he would be at risk of ricketts because of a vitamin C deficiency however college students have passed sailors as the group of people most at risk for Vit C defic.

Bleeding deficiencies effects in factors VII, IX, X and prothrombin

Fat

Meat, fish, eggs, milk, green veggies, enriched foods

Cheilitis, glossitis stomatitis, mucosal edema

Pork, grains, peas, dried beans, brewer's yeast,

CHO metabolism, nerve functioning

Poverty, alcoholics

• Beriberi- tingling poor coordination, weakness, edema possible cardiac dysfunction
• Wernikes encephalopathy

thamine deficiencies

Thamine deficiency

riboflavin

Vitamin K

Vitamin D

Vitamin C

Vitamin D

Vitamin A