primary care II
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Client presents with Hematemesis and Melena what are the D/Dx?
- ulcer (most likely)
- mallory-weiss tear
- Gastritis, Gastric CA
wht are the 3 major causes of PUD
- H. Pylori
Client is diagnosised with Mallory Weiss tear what is the treatment?
no treatment needed, it will resolve in 24-48 hours on it's own, just offer reassurance
Client presents with localized epigastric pain (dyspepsia). He describes a gnawing, dull, aching or "huner like" pain with relief from food or antiacids but the pain recurrs in 2-4 hours. pain is common at night. No pain with palpation, mild epigastric tenderness is found with deep palpation over epigastrium. What is your dx?
How will you confirm PUD dx?
- upper endoscopy.
- Labs are normal in uncomplicated disease.
When is the greatest risk for developing an ulcer from NSAID therapy?
the first 3 weeks
What age group should you be concerned about new ulcer development when perscribing NSAIDS?
Which ethinic group is most likely to have gastric CA?
You think your patient may have H. Pylori what tests can you do?
- urea breath test
- Stool antigen test
- endoscopic biopsy
how is H. PYlori treated?
- PPI + clarithromycin 500mg BID + Amoxicillin 500mg BID x7 days
- allergy to PCN use flagyl instead of amoxicillin.
what are some causes of anorectal bleeding?
- 50% hemorrhoids
- 20% anal fissure
- 15% colorectal disease
- 5% peri-anal dkinproblems
- 5% neoplasm
- 5% IBD
Client reports anaorectal bleeding. If blood loss is signifigant what PE will quickly alert you?
- postural hypotension (orthostatic)
- slow chronic blood loss may not be orthostatic but omplaint of fatigue and Dyspnea are common.
when the MCV is low what type of anemia is this?
Client is having steatorrhea what are the potential causes?
- short bowel syndrom
- may occur s/p gastric bypass-inquire
Client present with fatigue, and muscle pains. She also complains of bloating, abdominal discomfort generalized. during ROS you learn she has really smelly stools, has embarrasing flatulence, and weight loss of 10 lbs. She now reports bruising, and some LE edema. Her last CBC showed iron deficiency. What is your D/Dx?
- Celiac Sprue,
- could also be lactose intolerance
what serum test is used for Celiac Sprue dx
IgA endomysial antibody & IgA tTG antibody
Besides the IgA endomysial antibody and IgA tTg antibody testing for Celiac Sprue what other labs should you check?
iron, Folate, Vitamin D, Calcium, Alk PHos, albumin
A client asks you, "what is Gluten anyway?"
a protein found in grains- wheat, rye, barly, oat
Gastroparesis, delayed gastric emptying, what causes this?
altered metabolism (DM), mechanical or outlet obstruction.
- obstruction may be blockage (tumor),
- narrowing (PUD complication)
- or alteration in electromechanical activity (opiates)
Client presents with N&V, postprandial abdominal pain, ealry satiety and bloating. Some reflux pain-taste vomit. client is a diabetic in poor control and takes percocet PRN for low back pain. What are you thinking?
- mesenteric ischemia
Your diagnosis is gastroparesis what is the treatment?
- Reglan (short term-risk of tarkive dyskenisia non-reversible)
Who is most likely to present with gallbladder disease?
Fat, Fertile, Female, forty, with a family Hx.
what duct is shared between the pancrease and the gall bladder?
common bile duct
Your fat, forty yr-old, female client c/o not being able to eat chips or mcdonalds without getting nauseated. She belches a lot and has pain in RUQ that is unbearable. Positive Murphy's sign on exam. what are your D/DX?
You suspect cholecystitis what test will you order?
ultrasound of gallbladder and billiary tree
Client presents with bloody diarrhea and abdominal pain LLQ, slight fever, no appetite. She is caucasion and age is 19. She also has joint pains and a new dermatitis rash with ulcerations on right elbow. Mother has diverticulitis and brother has IBS. what D/Dx?
- ulcerative colitis since she is young, white and this is first episode. Also seen with arthritis, uveitis, jaundice and skin lesions.
This disorder is an idiopathic diffuse inflammatory disease of the distal colon and rectum. Mucosa becomes edematous, granular appearance and the bowel wall becomes friable with spontaneous bleeding. It can be diagnosed with flex sigmoid. What is it?
How is UC treated?
- tx inflammation with steroids--prednisone
- sulfasalazine for initial diagnosis.
how do you tell the difference between Crohn's and UC?
- UC is not recurrent, inflammation is localized to distal colon, pain is LLQ
- Crohn's is relapsing, skip lesions occur all along intestine, RLQ abdominal pain.
This is a chronic relapsing inflammatory disorder with an autoimmune pathoology.
It usually first occurs in the 30's-40's.
Affects the distal ileum and right colon
RLQ pain wt loss, vomiting, diarrhea &/or constipation.
bleeding is common.
What is it?
What is the treatment for Crohn's?
- tx inflammation with steroid prednisone
- sulfasalazine may help
- (same symptom treatment for UC and Crohn's)
The client came in with bloody diarrhea and LLQ pain. You send her for a colonoscopy and the report shows your client has thinning of the colon wall of the large intestine with continuous inflammation. There are no granulomas and the rectum is involved, what is the diagnosis?
This is a functional disturbance of intestinal motility and visceral perception. It is a diagnoisis of exclusion. Presentation may be diarrhea &/or constipation. Clients are usually <40 yr old. Pain is crampy and relieved by BM. usually no disruption of sleep. What is it?
What is the treatment for IBS
- Dietary- fiber manage consitpation/diarrhea
- anticholinergics bentyl 10-20 mg AC PRN is helpful
- SSRI Zoloft
client presents with RLQ pain doesn't want to move, no bloody diarrhea but postiive for N&V. rebound tenderness. Waht are you thinking this might be?
What is the test & treatment for appendicitis?
- CBC with diff and CT
- surgical treatment refer
The client presents with epirgastric periumbilical pain both Right and left upper quads and back pain. Feels better when I stand or sit upright. Can't eat I vomit, no matter what I take in. Abdomin is tender, and slightly distended. bowel sounds are decreased. she has a low grade fever. What are you thinking this might be?
What are the tests to determine if your client has pancreatitis?
serum Amylase and Lipase (amylase is best predictor)
How do you treat pancreatitis?
- most resolve spontaneously.
- low fat diet, H2 receptor antagonist (pepcid), antacids and anticholinergics.
- stop ETOH, manage tryglicerides
This is a common finding in mature adults. often asymtomatic and found during a screening colonoscopy. when it does become problematic it usually seen in the sigmoid colon. When it acts up it produces LLQ pain, a tender mass may be palpable, fever and leukocytosis are usually present. What is this?
How is symptomatic diverticulitis treated?
- bowel rest clear liquids the high fiber diet & avoid things with nuts.
- bactrim (sulfa) or augmentin (PCN) or
- cipro + flagyl especially with fevers
- CONTRAINDICATED antipyretics & analgesics
What kind of bowel sounds do you find in pancreatitis?
A client with diverticulitis has 3-4 episodes a year how will you manage this person?
refer for surgical consult
You started your diverticulitis patient on antibiotics. she asks how long before I feel better. you tell her...
in the next 48 hours
primary headaches are usually responsive to what medication?
what does SNOOP stand for?
- headache differntiation primary or seconday. If any of these are present you must work up the headache for secondary cause, like SAH.
- Systemic symptoms?
- Neurological signs
- Old Age
- Progression, changes to previous presentation.
this tye of headache usually wakes people up about 1 hour after they fall asleep. Sometimes call suicide headache. what kind of headache is this?
What is the most common type of headache?
what is the most common type of headache seen in outpatient practice?
if an aura is visual anomoly or smell (but not weakness) which comes on about 30 minutes prior to the migraine what is a prodrome?
yawning, feeling tired, od or not right. it is not an aura.
Client tells you he has sinus congestion that is clear and watery eyes with his headaches. what type of headache is this?
how long does a tension headache last?
24 hours to 1 week!
Cllient tell you her headache comes on between 4-6am, and she ususally is nauseated. The headache lasts for 4-72 hours, is throbbing and severe. what kind of headache is this most likely to be?
what is meant by 2+1=migraine
- any 2 of these sx: throbbing, one sided, increase pain with mvmt or mod-severe
- + and 1 of these sx: N&V, phophobia, pain with sound.
You perform SNOOP on a person with a headache complaint and find a a potential neurological symptom. what tests should you order?
- consider CT/MRI depending on what the sx is.
what common medication can induce headaches?
What are the peak ages for migraine complaints to surface (besides adolesence with early menstration).
what is the prophylaxis treatment for cluster headache?
what is the triggers to avoid with cluster headaches/
smoking and ETOH
What therapies are availble to abort a cluster headache?
oxygen and sumatriptan
Client presents with headache that will not let up what "emergency" medications can you consider?
- valproic acid
what medications are prophylaxis for headache ?
- beta blockers
- SSRI, TCA
You want to perscribe abortive medication for your client with migraine. What can you consider?
- nsaids + triptan (sumatriptan is imitrex)
- ergotamine + caffine
the 3 treatment or management focus of atrial fibrillation are ....
- Rate control
- rythm control
Your client is 32 years old, healthy, non- smoker, BMI 21, social ETOH use and presents with c/o palpitations. She is slightly orthostatic, & her HR is irregular. There is a 15 beat difference between her apical & radial rate. no murmurs or sounds suggestive of Valve disease. EKG shows Afib. what type of afib is this?
- lone afib
- afib in the absence of heart diseas or cardiovascular risk factors.
What is this the definition of?
SVT with uncoordinated atrical activation and consequent deterioration of atrial mechanical function.
What is the differntial for atrial fibrillation?
Survival and stoke rates are the same regardless if Lone AF episodes are paroxysmal or chronic. So what does affect risk?
New new AF occurs in your client with known Aortic valve disease what does this suggest?
increasing severity of vavlular disease.
whith atrial fibrillation or atrial flutter where is a blood clot most likely to form?
Treatemnt for WPW with AF?
Amio + DCC
what are the calaric needs for energy for sedintary persons?
what are the caloric needs for energy for active peep?
Keep fats <____% of diet and sat fat to 10%
which fat is good fat?
good fat is un sat fat
what are the protien requirements (g/kg) for Diabetics/
- 0.8g/kg (>65 1g/kg)
- more is always better unless renal
name some protien sources
- lowfat milk
- lentils beans
how much of the diet should be carbs/
45-50% about 900kcal or 225 g (15 exchanges of carbs/day)
what are the 2 essential AA needed for wound healing?
argenine and gltuamine
what food has all the nessisary amino acids?
what suppliment is best for wound healing and why?
ensure enhanced b/c it has HMB which is a metabolite of lucience
name some anti-inflammatory foods I can use in my diet?
- red and green peppers
what is the minimum carb intake (grams) for brain function?
your clients asks what they can to to improve their HDL. What will you tell them?
- quit somoking, moderate ETOH intake
- loose 5-10% weight in 6 months
- niacin fibrates or statins
- whole grains or oats
- plant sterols 9promis margerine)
- omega 3
Your client asks how they can improve their LDL. what will you tell them?
- soluable fiber: kidney beans, apples, pears, barley
what are some examples of insoluable fiber foods. These will fill you up and create a barrier for absorbing colesterol helps with digestion issues too.
- whole wheat bread, cereals
- rice barley grains
- apple skin
what food is good for HF?
what does DASH stand for?
Dietary Approach to stop HTN
how much sodium should you recommend your client strive for if they have HTN or CHF?
- 1g per day but it is hard
- all others are 2-2.5g/day
your client has a BMI of 27. how would you classify this? normal, fat, overweight, obese...
overweight (BMI 25-29.9)
Your client has a BMI of 35 what would this be classified as?
obese class II (BMI 35-39.9
1 starch is how many grams
1 fruit equal how many grams?
1 fruit is how many grams
what kind of CCB's are used for rate control in a fib?
NDH cardizem or verapimil
When do you consider dig in treating afib?
HF with LVH
What would you like to do?
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