Podcast
Questions and Answers
Which condition, associated with RLQ pain, anorexia, nausea, vomiting, and potentially constipation or diarrhea, is a common cause of abdominal pain?
Which condition, associated with RLQ pain, anorexia, nausea, vomiting, and potentially constipation or diarrhea, is a common cause of abdominal pain?
- Ruptured Aortic Aneurysm
- Small Bowel Obstruction
- Peritonitis
- Appendicitis (correct)
A patient presents with intermittent, crampy abdominal pain, vomiting, obstipation, and abdominal distention. Hyperactive bowel sounds and fever are noted. What condition is most likely?
A patient presents with intermittent, crampy abdominal pain, vomiting, obstipation, and abdominal distention. Hyperactive bowel sounds and fever are noted. What condition is most likely?
- Small Bowel Obstruction (correct)
- Ruptured Aortic Aneurysm
- Appendicitis
- Perforated Peptic Ulcer
A patient experiences a sudden onset of severe abdominal pain followed rapidly by peritoneal signs. This presentation is most indicative of which condition?
A patient experiences a sudden onset of severe abdominal pain followed rapidly by peritoneal signs. This presentation is most indicative of which condition?
- Small Bowel Obstruction
- Ruptured Aortic Aneurysm
- Perforated Peptic Ulcer (correct)
- Peritonitis
A patient presents with a high fever and acute abdominal pain that may be diffuse, localized, or referred, accompanied by vomiting and diarrhea/constipation. Which condition is most likely?
A patient presents with a high fever and acute abdominal pain that may be diffuse, localized, or referred, accompanied by vomiting and diarrhea/constipation. Which condition is most likely?
A patient reports a sudden onset of severe abdominal pain that may be confined to the flank, low back, or groin, potentially preceded by abdominal, flank, or back pain. Which condition is most indicative?
A patient reports a sudden onset of severe abdominal pain that may be confined to the flank, low back, or groin, potentially preceded by abdominal, flank, or back pain. Which condition is most indicative?
When evaluating a patient with abdominal pain, which of the following diagnostic tests would be LEAST helpful in determining the underlying cause?
When evaluating a patient with abdominal pain, which of the following diagnostic tests would be LEAST helpful in determining the underlying cause?
A patient presents reporting right lower quadrant (RLQ) pain, nausea, and a low-grade fever. Which physical exam finding would MOST strongly suggest appendicitis?
A patient presents reporting right lower quadrant (RLQ) pain, nausea, and a low-grade fever. Which physical exam finding would MOST strongly suggest appendicitis?
Which of the following physical findings is MOST associated with small bowel obstruction rather than other causes of abdominal pain?
Which of the following physical findings is MOST associated with small bowel obstruction rather than other causes of abdominal pain?
A patient presents with suspected appendicitis. Which of the following diagnostic findings would be MOST indicative of potential perforation?
A patient presents with suspected appendicitis. Which of the following diagnostic findings would be MOST indicative of potential perforation?
Upon assessing a patient, you elicit pain with right thigh extension. Which sign does this MOST likely indicate?
Upon assessing a patient, you elicit pain with right thigh extension. Which sign does this MOST likely indicate?
A patient with suspected appendicitis experiences right lower quadrant (RLQ) pain upon palpation of the left lower quadrant (LLQ). Which of the following signs is being demonstrated?
A patient with suspected appendicitis experiences right lower quadrant (RLQ) pain upon palpation of the left lower quadrant (LLQ). Which of the following signs is being demonstrated?
For a patient suspected of having appendicitis, current guidelines recommend performing an appendectomy within what timeframe from symptom onset to minimize the risk of perforation?
For a patient suspected of having appendicitis, current guidelines recommend performing an appendectomy within what timeframe from symptom onset to minimize the risk of perforation?
When assessing a patient with a small bowel obstruction, which finding would suggest the obstruction is progressing to strangulation, requiring more urgent surgical intervention?
When assessing a patient with a small bowel obstruction, which finding would suggest the obstruction is progressing to strangulation, requiring more urgent surgical intervention?
A patient undergoing evaluation for a possible small bowel obstruction would have which finding on diagnostic imaging to confirm the diagnosis?
A patient undergoing evaluation for a possible small bowel obstruction would have which finding on diagnostic imaging to confirm the diagnosis?
Which feature is MOST characteristic of internal hemorrhoids?
Which feature is MOST characteristic of internal hemorrhoids?
You are evaluating a patient complaining of rectal bleeding and discomfort. How is the prolapse of internal hemorrhoids classified?
You are evaluating a patient complaining of rectal bleeding and discomfort. How is the prolapse of internal hemorrhoids classified?
When examining a patient to diagnose hemorrhoids, what procedure plays a critical role because because it allows direct visualization of the entire anus and distal rectum?
When examining a patient to diagnose hemorrhoids, what procedure plays a critical role because because it allows direct visualization of the entire anus and distal rectum?
For which anorectal condition would a healthcare provider MOST likely perform a colonoscopy?
For which anorectal condition would a healthcare provider MOST likely perform a colonoscopy?
What is the MOST appropriate first-line treatment for symptomatic hemorrhoids?
What is the MOST appropriate first-line treatment for symptomatic hemorrhoids?
When is surgical excision MOST appropriate for a thrombosed external hemorrhoid?
When is surgical excision MOST appropriate for a thrombosed external hemorrhoid?
Which of the following is a common cause of anal fissures?
Which of the following is a common cause of anal fissures?
What physical exam finding would MOST strongly suggest the presence of a CHRONIC anal fissure rather than an acute one?
What physical exam finding would MOST strongly suggest the presence of a CHRONIC anal fissure rather than an acute one?
A patient is diagnosed with an acute anal fissure but is unable to tolerate topical treatments due to severe irritation. What is the MOST appropriate next step?
A patient is diagnosed with an acute anal fissure but is unable to tolerate topical treatments due to severe irritation. What is the MOST appropriate next step?
What intervention is considered the gold standard for treating chronic anal fissures that have not healed with conservative treatments?
What intervention is considered the gold standard for treating chronic anal fissures that have not healed with conservative treatments?
What is the MOST common cause of cholecystitis?
What is the MOST common cause of cholecystitis?
Which of the following is a known risk factor for cholelithiasis?
Which of the following is a known risk factor for cholelithiasis?
When assessing a patient with suspected acute cholecystitis, which of the following examination findings is MOST specific to this condition?
When assessing a patient with suspected acute cholecystitis, which of the following examination findings is MOST specific to this condition?
What diagnostic test is considered the MOST accurate for confirming a diagnosis of cholecystitis?
What diagnostic test is considered the MOST accurate for confirming a diagnosis of cholecystitis?
A patient presents to the clinic with right upper quadrant pain and is ultimately diagnosed with cholelithiasis. Of the following medications, which may cause cholelithiasis?
A patient presents to the clinic with right upper quadrant pain and is ultimately diagnosed with cholelithiasis. Of the following medications, which may cause cholelithiasis?
What is the MOST appropriate initial management for symptomatic gallbladder disease caused by cholelithiasis?
What is the MOST appropriate initial management for symptomatic gallbladder disease caused by cholelithiasis?
What is the MOST common cause of cirrhosis?
What is the MOST common cause of cirrhosis?
What is the MOST accurate way to diagnose the CAUSE of cirrhosis?
What is the MOST accurate way to diagnose the CAUSE of cirrhosis?
A patient with cirrhosis develops ascites. What dietary modification is MOST important?
A patient with cirrhosis develops ascites. What dietary modification is MOST important?
What is MOST important to include in the management plan for a patient with cirrhosis and hepatic encephalopathy?
What is MOST important to include in the management plan for a patient with cirrhosis and hepatic encephalopathy?
According to the Rome III criteria, how many bowel movements per week is generally considered consistent with chronic constipation?
According to the Rome III criteria, how many bowel movements per week is generally considered consistent with chronic constipation?
Long term constipation can be caused by a number of lifestyle factors. Constipation could result from all of the following EXCEPT:
Long term constipation can be caused by a number of lifestyle factors. Constipation could result from all of the following EXCEPT:
A patient reports symptoms of chronic constipation and alarm symptoms are ruled out. What is the BEST initial step in managing this patient's constipation?
A patient reports symptoms of chronic constipation and alarm symptoms are ruled out. What is the BEST initial step in managing this patient's constipation?
If increased fiber and osmotic laxatives don't relieve constipation, what should be prescribed next?
If increased fiber and osmotic laxatives don't relieve constipation, what should be prescribed next?
Which of the following characteristics is MOST consistent with non-infectious diarrhea?
Which of the following characteristics is MOST consistent with non-infectious diarrhea?
A patient mentions that their stools are greasy, bulky, and have a rancid smell. Which problem is MOST likely?
A patient mentions that their stools are greasy, bulky, and have a rancid smell. Which problem is MOST likely?
What is primarily associated with diverticulitis?
What is primarily associated with diverticulitis?
A patient is diagnosed with diverticulitis but without any complications. What instructions should they receive regarding physical activity?
A patient is diagnosed with diverticulitis but without any complications. What instructions should they receive regarding physical activity?
A patient is diagnosed with dysphagia. What should occur first?
A patient is diagnosed with dysphagia. What should occur first?
A middle-aged patient presents with signs of acute abdomen. Upon examination, the patient exhibits orthostatic vital sign changes and severe, localized lower abdominal pain. Considering the information provided, what is the MOST appropriate next step?
A middle-aged patient presents with signs of acute abdomen. Upon examination, the patient exhibits orthostatic vital sign changes and severe, localized lower abdominal pain. Considering the information provided, what is the MOST appropriate next step?
A patient presents to the clinic with right upper quadrant abdominal pain. To BEST differentiate between cholelithiasis and cholecystitis, which of the following questions is MOST relevant?
A patient presents to the clinic with right upper quadrant abdominal pain. To BEST differentiate between cholelithiasis and cholecystitis, which of the following questions is MOST relevant?
A patient with known cirrhosis presents with recent onset ascites. After initiating dietary sodium restriction, which medication is MOST appropriate?
A patient with known cirrhosis presents with recent onset ascites. After initiating dietary sodium restriction, which medication is MOST appropriate?
An elderly patient reports chronic constipation. Initial management includes increased fiber and osmotic laxatives, which have provided minimal relief. What is the MOST appropriate NEXT step in managing this patient's constipation?
An elderly patient reports chronic constipation. Initial management includes increased fiber and osmotic laxatives, which have provided minimal relief. What is the MOST appropriate NEXT step in managing this patient's constipation?
A patient presents with new-onset dysphagia. After initial assessment, the provider suspects a motility disorder. Which of the following would be MOST appropriate to confirm this suspicion, determine the location, and assess for aspiration?
A patient presents with new-onset dysphagia. After initial assessment, the provider suspects a motility disorder. Which of the following would be MOST appropriate to confirm this suspicion, determine the location, and assess for aspiration?
In assessing a patient presenting with acute abdominal pain, which finding would necessitate specialist referral?
In assessing a patient presenting with acute abdominal pain, which finding would necessitate specialist referral?
When evaluating a patient for a suspected ruptured aortic aneurysm, what aspect of their history would be MOST concerning?
When evaluating a patient for a suspected ruptured aortic aneurysm, what aspect of their history would be MOST concerning?
Which diagnostic test would be MOST useful in differentiating between various causes of acute abdominal pain?
Which diagnostic test would be MOST useful in differentiating between various causes of acute abdominal pain?
When managing a patient with acute abdominal pain secondary to suspected diverticulitis, if the patient has a fever of 101.5°F (38.6°C) and signs of localized peritonitis, what is the MOST appropriate course of action?
When managing a patient with acute abdominal pain secondary to suspected diverticulitis, if the patient has a fever of 101.5°F (38.6°C) and signs of localized peritonitis, what is the MOST appropriate course of action?
A patient's history includes acute salpingitis, gastroenteritis and ruptured ectopic pregnancy. This information is MOST relevant when considering which aspect of their current abdominal pain complaint?
A patient's history includes acute salpingitis, gastroenteritis and ruptured ectopic pregnancy. This information is MOST relevant when considering which aspect of their current abdominal pain complaint?
When evaluating a patient's anorectal complaints, what is the PRIMARY purpose of performing anoscopy?
When evaluating a patient's anorectal complaints, what is the PRIMARY purpose of performing anoscopy?
Which of the following situations warrants specialist referral for abdominal pain?
Which of the following situations warrants specialist referral for abdominal pain?
What is the PRIMARY goal of conservative management for symptomatic hemorrhoids?
What is the PRIMARY goal of conservative management for symptomatic hemorrhoids?
A middle-aged patient reports painful bowel movements and blood on the toilet paper. Clinical exam reveals a small tear in the distal anal canal. What should be the INITIAL recommendation?
A middle-aged patient reports painful bowel movements and blood on the toilet paper. Clinical exam reveals a small tear in the distal anal canal. What should be the INITIAL recommendation?
What is the rationale behind avoiding opioid prescriptions for patients with anal fissures?
What is the rationale behind avoiding opioid prescriptions for patients with anal fissures?
In a patient presenting with severe anorectal pain, what is the rationale for considering the timing of surgical intervention for a thrombosed external hemorrhoid?
In a patient presenting with severe anorectal pain, what is the rationale for considering the timing of surgical intervention for a thrombosed external hemorrhoid?
What is the MOST appropriate initial step in managing a patient with suspected acute cholecystitis?
What is the MOST appropriate initial step in managing a patient with suspected acute cholecystitis?
What symptom separates cholelithiasis from cholecystitis?
What symptom separates cholelithiasis from cholecystitis?
When planning care for a patient with symptomatic cholelithiasis, what dietary recommendation is MOST appropriate?
When planning care for a patient with symptomatic cholelithiasis, what dietary recommendation is MOST appropriate?
A patient is diagnosed with cirrhosis. What aspect of their history is MOST important for management decisions?
A patient is diagnosed with cirrhosis. What aspect of their history is MOST important for management decisions?
A patient with cirrhosis and hepatic encephalopathy is being discharged. Which laboratory parameter is MOST crucial to monitor regularly?
A patient with cirrhosis and hepatic encephalopathy is being discharged. Which laboratory parameter is MOST crucial to monitor regularly?
How should a provider counsel a patient with cirrhosis regarding sodium intake when managing new-onset ascites?
How should a provider counsel a patient with cirrhosis regarding sodium intake when managing new-onset ascites?
Which of the following symptoms would cause a provider to suspect SBO as the cause of acute abdominal pain?
Which of the following symptoms would cause a provider to suspect SBO as the cause of acute abdominal pain?
To help diagnose between different causes of referred abdominal pain, all of the following should be documented EXCEPT:
To help diagnose between different causes of referred abdominal pain, all of the following should be documented EXCEPT:
What is the MOST appropriate initial instruction for a patient with infrequent bowel movements who reports straining?
What is the MOST appropriate initial instruction for a patient with infrequent bowel movements who reports straining?
What is the PRIMARY goal when managing constipation with increased intestinal transit time?
What is the PRIMARY goal when managing constipation with increased intestinal transit time?
When evaluating a patient with anorexia and chronic diarrhea, which historical factor would MOST suggest malabsorption?
When evaluating a patient with anorexia and chronic diarrhea, which historical factor would MOST suggest malabsorption?
During an evaluation for diarrhea, a patient reports a history of malabsorption and weight loss. Which area should be prioritized during the history and physical exam?
During an evaluation for diarrhea, a patient reports a history of malabsorption and weight loss. Which area should be prioritized during the history and physical exam?
A patient with symptoms of fever, LLQ pain, and constipation wants to be managed with diet instead of antibiotics. How should this be addressed?
A patient with symptoms of fever, LLQ pain, and constipation wants to be managed with diet instead of antibiotics. How should this be addressed?
An elderly patient with a history of dysphagia is diagnosed with malnutrition and dehydration. How can they achieve adequate nutrition?
An elderly patient with a history of dysphagia is diagnosed with malnutrition and dehydration. How can they achieve adequate nutrition?
How can a provider evaluate the need for further testing when diagnosing dysphagia?
How can a provider evaluate the need for further testing when diagnosing dysphagia?
Which of the following patients would MOST likely require cough-based dysphagia treatment?
Which of the following patients would MOST likely require cough-based dysphagia treatment?
What diagnosis can be suspected from bloody or mucus-filled stools and generalized spasms during a diarrhea evaluation?
What diagnosis can be suspected from bloody or mucus-filled stools and generalized spasms during a diarrhea evaluation?
A provider is evaluating a patient for abdominal pain and wants to use diagnostic testing. If a patient is experiencing nausea and vomiting, what is the best choice?
A provider is evaluating a patient for abdominal pain and wants to use diagnostic testing. If a patient is experiencing nausea and vomiting, what is the best choice?
What is the goal in managing cirrhosis with medications like Tylenol, amiodarone and varied antibiotics?
What is the goal in managing cirrhosis with medications like Tylenol, amiodarone and varied antibiotics?
What is the most important aspect of providing the best quality of care with cirrhosis treatment?
What is the most important aspect of providing the best quality of care with cirrhosis treatment?
Which of the following interventions is MOST appropriate for managing acute diarrhea?
Which of the following interventions is MOST appropriate for managing acute diarrhea?
The most appropriate choice when addressing both bacterial balance and malabsorption is which plan?
The most appropriate choice when addressing both bacterial balance and malabsorption is which plan?
Which initial treatment for constipation will address stool softening?
Which initial treatment for constipation will address stool softening?
A patient has been educated regarding increasing their fluid and fiber intake in order to address constipation. They've been referred for physical activity to help. What is the purpose?
A patient has been educated regarding increasing their fluid and fiber intake in order to address constipation. They've been referred for physical activity to help. What is the purpose?
After diagnosing diverticulitis, what lifestyle changes should be discussed with a patient?
After diagnosing diverticulitis, what lifestyle changes should be discussed with a patient?
A patient presents with abdominal pain and jaundice. Based on the information provided, which of the following conditions warrants specialist referral?
A patient presents with abdominal pain and jaundice. Based on the information provided, which of the following conditions warrants specialist referral?
A patient with anorectal complaints is undergoing an evaluation. What is the PRIMARY diagnostic utility of performing anoscopy?
A patient with anorectal complaints is undergoing an evaluation. What is the PRIMARY diagnostic utility of performing anoscopy?
You're counseling a patient with symptomatic cholelithiasis who is managing their condition non-surgically. Which dietary recommendation is MOST appropriate for this patient?
You're counseling a patient with symptomatic cholelithiasis who is managing their condition non-surgically. Which dietary recommendation is MOST appropriate for this patient?
What is the MOST important aspect of providing high-quality care for a patient with cirrhosis?
What is the MOST important aspect of providing high-quality care for a patient with cirrhosis?
A patient reports new-onset dysphagia. After the initial assessment, the provider suspects a structural disorder. What finding would MOST strongly support the need for referral to GI?
A patient reports new-onset dysphagia. After the initial assessment, the provider suspects a structural disorder. What finding would MOST strongly support the need for referral to GI?
Flashcards
When is specialist referral indicated?
When is specialist referral indicated?
Indicated for suspected GI bleeding or bowel obstruction.
What are the signs of appendicitis?
What are the signs of appendicitis?
A condition with RLQ pain, anorexia, nausea/vomiting, and low-grade fever.
What indicates a small bowel obstruction?
What indicates a small bowel obstruction?
A condition marked by intermittent abdominal pain, vomiting, and abdominal distention.
Signs of a perforated peptic ulcer?
Signs of a perforated peptic ulcer?
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What are the sign of peritonitis?
What are the sign of peritonitis?
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What are the signs of a ruptured aortic aneurysm?
What are the signs of a ruptured aortic aneurysm?
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Initial steps in examining abdominal pain?
Initial steps in examining abdominal pain?
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What could mimic appendicitis?
What could mimic appendicitis?
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What is the initial step in managing abdominal pain?
What is the initial step in managing abdominal pain?
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What is the typical appendicitis pain progression?
What is the typical appendicitis pain progression?
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What does a positive Psoas sign indicate?
What does a positive Psoas sign indicate?
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What does a positive Obturator's sign indicate?
What does a positive Obturator's sign indicate?
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What do X-rays show in SBO?
What do X-rays show in SBO?
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What are hemorrhoids?
What are hemorrhoids?
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Internal versus external hemorrhoids?
Internal versus external hemorrhoids?
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External hemorrhoids?
External hemorrhoids?
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What are signs of hemorrhoids?
What are signs of hemorrhoids?
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How do you diagnose hemorrhoids?
How do you diagnose hemorrhoids?
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Why can pregnancy trigger hemorrhoids?
Why can pregnancy trigger hemorrhoids?
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What defines an anal fissure?
What defines an anal fissure?
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What are common symptoms of Anal fissure?
What are common symptoms of Anal fissure?
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What do Perineal and rectal exams show in anal fissures?
What do Perineal and rectal exams show in anal fissures?
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What conservative treatments for fissures?
What conservative treatments for fissures?
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Define cholecystitis.
Define cholecystitis.
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What is cholelithiasis?
What is cholelithiasis?
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What are the types of gallstones?
What are the types of gallstones?
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When the gallbladder inflamed, what happens?
When the gallbladder inflamed, what happens?
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What sensations accompany chronic cholecystitis?
What sensations accompany chronic cholecystitis?
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How is Acute version different?
How is Acute version different?
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Distended gallbladder?
Distended gallbladder?
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How do you diagnose?
How do you diagnose?
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Cholelithiasis risk?
Cholelithiasis risk?
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What do you do?
What do you do?
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Cirrhosis?
Cirrhosis?
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Why does cirrhosis occur?
Why does cirrhosis occur?
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Cirrhosis caused by?
Cirrhosis caused by?
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What early symptoms cirrhosis?
What early symptoms cirrhosis?
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What do you feel in cirrhosis
What do you feel in cirrhosis
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How would you assess it?
How would you assess it?
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How do you deal?
How do you deal?
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Warning signs?
Warning signs?
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More stool?
More stool?
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How to deal!
How to deal!
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Diverticolosis
Diverticolosis
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Signs of
Signs of
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Why is abdominal pain a common primary care complaint?
Why is abdominal pain a common primary care complaint?
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Clinical sign of Perforated Peptic Ulcer
Clinical sign of Perforated Peptic Ulcer
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Clinical sign of Peritonitis
Clinical sign of Peritonitis
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Signs of Small Bowel Obstruction
Signs of Small Bowel Obstruction
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What diagnostics are used for abdominal complaints?
What diagnostics are used for abdominal complaints?
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How do you manage abdominal pain/infection?
How do you manage abdominal pain/infection?
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Further Management for Abdominal pain and infection
Further Management for Abdominal pain and infection
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Lab findings in appendicitis
Lab findings in appendicitis
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Lab findings in Small Bowel Obstruction
Lab findings in Small Bowel Obstruction
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Appendicitis Management
Appendicitis Management
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Small Bowel Obstruction Management
Small Bowel Obstruction Management
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What are anorectal complaints?
What are anorectal complaints?
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Where are internal Hemorrhoids located?
Where are internal Hemorrhoids located?
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Where are external Hemorrhoids located?
Where are external Hemorrhoids located?
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Clinical Presentation for External Hemorrhoids.
Clinical Presentation for External Hemorrhoids.
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Diagnoses for Anorectal Complaints
Diagnoses for Anorectal Complaints
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Conservative Hemorrhoid Treatment
Conservative Hemorrhoid Treatment
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Differentials for anal fissures
Differentials for anal fissures
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How does Cholelithiasis and Cholecystitis form?
How does Cholelithiasis and Cholecystitis form?
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Pathophysiology of Cholecystitis.
Pathophysiology of Cholecystitis.
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Physical Exam findings in Cholelithiasis
Physical Exam findings in Cholelithiasis
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Cirrhosis Common Causes
Cirrhosis Common Causes
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How is perineal descent measured in constipated patients.
How is perineal descent measured in constipated patients.
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Why does secondary constipation occur?
Why does secondary constipation occur?
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Define Diarrhea
Define Diarrhea
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Assessing cause of Diarrhea
Assessing cause of Diarrhea
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Management for Diarrhea
Management for Diarrhea
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Medical mgmt. to treat ascites
Medical mgmt. to treat ascites
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What is diverticulosis
What is diverticulosis
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Study Notes
Abdominal Pain and Infections
- Abdominal pain is a common complaint in primary care
Etiology and Referral
- Acute abdominal pain can indicate an emergency referral
- Symptoms are subjective, specialist referral is needed if:
- Suspected GI bleeding
- Bowel obstruction
- Orthostatic vital sign changes
- Abnormal findings
- Jaundice
- Positive pregnancy test
- Severe localized or unilateral pain
- History of trauma
- Any sign of peritoneal irritation
Conditions Associated with Abdominal Pain
- Appendicitis is indicated by RLQ pain, anorexia, nausea/vomiting, low-grade fever, constipation, or rarely diarrhea
- Small bowel obstruction is indicated by abdominal pain, vomiting, obstipation, abdominal distention, hyperactive bowel sounds, and fever
- Perforated peptic ulcer presents with sudden abdominal pain, followed by peritoneal signs
- Peritonitis can cause high fever and acute widespread, localized, or referred pain, vomiting, diarrhea, or constipation
- Ruptured aortic aneurysm may previously cause abdominal, flank, or back pain, acute rupture causes sudden severe abdominal pain from flank, low back, or groin
Physical Examination and Diagnostics
- Key components of Physical Exam:
- Assess vital signs
- Thorough PMHx
- Family Hx
- Medications review
- Complete physical exam
- Abdominal provocative screening tests
- CVA tenderness
- Diagnostic tests:
- Serum amylase and lipase
- CBC
- CRP
- Lactate dehydrogenase test
- Liver panel
- UA
- CT scan
- US
Differential Diagnoses
- Include gastroenteritis, mesenteric lymphadenitis, acute salpingitis, Mittelschmerz, ectopic or corpus luteum pregnancy, ureteral or Meckel's diverticulitis, perforated peptic ulcer, cholecystitis
- Other possible diagnosis include intestinal obstruction, cecal diverticulitis, intestinal ischemia, perforated colonic carcinoma, basilar pneumonia
Management Strategies
- Referral to the ED
- Surgery, in cases like appendectomy
- Hydration using intravenous fluids
- Proton pump inhibitors
- Empirical antibiotic therapy if indicated
- Surgical consult
- Collaborative interdisciplinary management
- Analgesia and treatment of the underlying cause
Appendicitis
- Symptoms include vague, colicky umbilical pain that shifts to point tenderness on RLQ, nausea/vomiting, and worsening pain with coughing
- Physical exam findings: RLQ guarding with rebound tenderness that is localized, Psoas sign with R thigh extension, Obturator's sign with internal rotation of flexed R thigh, Rosving's sign with RLQ pain with pressure to LLQ
- Lab and diagnostics include WBCs of 10,000-20,000, pregnancy test if childbearing age, CRP, amylase/lipase, CT scan/ultrasound
- Low-grade fever indicates high perforation risk
- Management includes ED referral for surgery or pain management and appendectomy within 24 hours of onset
Small Bowel Obstruction
- Signs and symptoms include cramping, intermittent umbilical pain, abdominal distension, hyperactive bowel sounds, fever, vomiting with pain, pain relief from vomiting with decompression
- Common causes are adhesions, hernias, or tumors
- Obstruction of the bowel lumen or paralysis (ileus) of the intestinal musculature result in SBO
- Physical findings may show minimal or pronounced abdominal distension and guarding, mild midabdominal rebound tenderness, and high-pitched bowel sounds
- Inability to pass stool or gas indicates SBO
- Diagnosis involves elevated WBC, plain films, xray or ultrasound, or CT scan showing dilated loops
- Management involes; NG suction for rehydration, broad spectrum antibiotics, GI surgical consult for pain, surgery if needed.
Anorectal Complaints: Hemorrhoids
- Very common, vascular cushions serve to connect muscular tissue within the anus
- Function: helps maintain anal closure and continence
Types of Hemorrhoids
- Internal hemorrhoids are above the dentate line and covered by columnar epithelium
- External hemorrhoids lie below the dentate line and are covered by squamous epithelium
Causes and Triggers
- Hemorrhoids are often due to diet, toileting habits, genetics, pregnancy, enlargement/prolapse of submucosal vascular tissue, and increased pelvic floor pressure
Clinical Presentations of Hemorrhoids
- Clinical findings for internal hemorrhoids:
- Bleeding
- Pruritus
- Protrusion
- Pain Internal hemorrhoids: almost always painless
- Intermittent, reducible protrusion after defecation, classified by degree of prolapse
- External Hemorrhoids: sensitive to touch/temperature, less likely to bleed, asymptomatic unless thrombosis occurs with tender lump
- Other findings could be palpable nodule/anal irritation
Diagnosing Hemorrhoids
- Inspection of the perineum and perianal area is key while patient is at rest or straining
- External hemorrhoids can be visualized
- Internal hemorrhoids are best visualized with an anoscope
- Palpate for abnormal lesions with rectal examination
- Internal hemorrhoid must be thrombosed to be felt
- CBC screening for anemia and fecal occult blood testing
- Anoscopy should be used for hemorrhoid diagnosis and visualization of the entire anus/distal rectum
- Colonoscopy should be performed if no bleeding is found age 50+ or with colon cancer family history
Differential Diagnoses
- Proctitis
- Inflammatory bowel disease
- Condyloma
- Other STDs
- Rectal prolapse
- Anal skin tags
- Hypertrophied anal papillae
- Rectal polyps
- Cancer
- Anal fissure
- Anal papillitis
Management
- Based on symptom severity:
- High-fiber diet with increased fluid intake (20–30 g of fiber per day)
- Bulk-forming agents and stool softeners
- Topical or oral analgesics
- Rectogesic (glyceryl trinitrate 0.2%)
- Topical nitro (0.4%) or nifedipine
- Hydrocortisone acetate creams
- Frequent warm water sitz baths
- Surgical excision if hemorrhoid is thrombosed within 3 days
Anal Fissures
- Painful linear cracks or tears in the lining of the anal canal distal to the anatomical dentate line
- Causes: Inflammatory bowel disease (IBD), cancer, Crohn’s disease, Tuberculosis, HIV, Syphilis, Leukemia, Trauma, frequent diarrhea, anal stenosis, etc...
Acute and Chronic Anal Fissures
- Acute: Less than 6 weeks and superficial with longitudinal tear distal anoderm
- Chronic: More than 6 weeks, is associated by edema and fibrosis, tender skin tags, and anal papilla
Clinical Presentation
- Sharp pain during and after bowel movement
- Small amounts of bright red rectal bleeding
- Tearing sensation when passing stool
- Avoidance from bowel movements dues to pain and hard stools
Diagnosis and Differentials
- Physical exam: Perineal erythema, heat, swelling, tenderness, and purulence.
- Acute/chronic anal fissure
- Diagnostic: Visual inspection, Complete blood count, Digital Rectal Exam and Anoscopy, Ultrasound, CT Scan/MRI
- Differential diagnosis: Crohn’s disease, pilonidal sinus, hidradenitis suppurativa, anorectal malignant neoplasm, sexually transmitted diseases, and lymphoma
Management Strategies
- Increasing fiber and softening stool will help minimize constipation and relax anal muscles
- Fiber supplements and sitz baths are first-line treatments
- Avoid opioids as they can worsen constipation
- Anesthetic should be used topically before BM
- For chronic anal fissures, use topical nitrates or calcium channel blockers
Cholelithiasis and Cholecystitis
- Inflammatory, infectious, neoplastic, metabolic, or congenital conditions that cause gallbladder issues
- Cholelithiasis: Formation of gallstones in the gallbladder
- Cholecystitis: Inflammation of the gallbladder
- Gallbladder inflammation is caused by gallstones blocking the bile duct
- Primary types of gallstones: cholesterol, pigmented, mixed, patterns
- Stone size determines the severity of distress
Pathophysiology of Gallstones
- Three primary types of stones: cholesterol, pigmented, mixed
- The gallbladder becomes inflamed as a result of various processes, including continued blockage of the cystic or common bile duct
- Small gallstones pass through the duct, avoiding further distress
- Larger stones obstruct the bile duct, causing increased pressure resulting in pain, nausea, and vomiting
Clinical Presentation and Physical Evaluation
- P.E: Patient may be unremarkable initially
- Gallstones are generally asymptomatic
- Symptomatic cholelithiasis may be caused by Intermittent or steady RUQ pain
- Chronic cases may be recurrent, caused by epigastric pain radiating
- Murphy's Sign: Deep pain on inhalation
- Acute cholecystitis develops similarly, though develops into anorexia, N/V and possible sepsis
- Hypoactive bowel sounds
- Jaundice may be present
Diagnostics and Differentials
- CBC with differential/CMP, UA, LFTS, Serum pancreatic enzymes, Serum electrolyte values, BUN and creatinine, Blood cultures if sepsis is suspected, hCGs if of childbearing age, Electrocardiography if cardiac risk factors or suspect cardiac involvement, .
- Ultrasound- gold standard to confirm diagnosis shows gallbladder thickening and murphy sign.
- CT scan is used if there is reason for doubt.
- Differential diagnoses include: bowel obstruction, pancreatitis, peptic ulcer disease, pneumonia
- Other diagnostics include: chronic cholecystitis, diverticulitis, gastritis, gastroenteritis, hepatitis or hepatic abscess, irritable bowel syndrome, myocardial ischemia or infarction, neoplasm, pelvic inflammatory disease, pyelonephritis, renal colic, or appendicitis
Management of Cholelithiasis and Cholecystitis
- Mnemonic for who is at risk for cholelithiasis:
- Age: Increasing age
- Body Habitus: Obesity, rapid weight loss
- Childbearing: Pregnancy
- Drugs: Estradiol, estrogen
- Ethnicity
- Female
- Family Hx
- If symptomatic or acute cholecystitis, consider cholecystectomy
- Initial treatment for symptomatic gallbladder disease: isotonic fluids and electrolyte correction (no oral hydration
- Pharmacologic therapy for acute cholecystitis: Prophylactic antibiotics (secondary infection can develop
Cirrhosis
- Cirrhosis is a complex irreversible disease caused by exposure to persistent toxins, resulting in liver failure
- End-stage liver consequence of persistent hepatic fibrosis affecting normal liver function
- Replacement of normal tissue with injuries leads to impaired nodule development
- High risk: Older men, T2D, alcohol abuse
Causes of Cirrhosis
- Alcohol
- Nonalcoholic liver disease
- Chronic Hepatitis B/C
- Tylenol, amiodarone, methotrexate, isoniazid, carbon tetrachloride
- Inherited idiopathic causes
Clinical Presentation of Cirrhosis
- Can't be insidious.
- Early S/Sx are nonspecific
- Prutitus -W/loss -Anorexia -Muscle Cramps
- Late stage-Jaundice
Physical Exam of Cirrhosis
- Jaundice
- Spider angiomas of face, check abd
- Gynecomastia
- Ascites
- Fatigue
- Tremors
- Muehrcke nails
Diagnostics and Differential Diagnosis
- Idiopathic
- Primary
- Hep C & Primary hepatic
- Cardiac failure
- Dx- Liver BX
Management
- Lactulose (encephalopathy)
- Wernicke Encephalopathy
- ascites - Spironolactone
Constipation
- A chronic disorder marked by a lack of vitality, low fluid intake, high fat/protein, decreased activity or medicines
- Less than 3 bowel movements per week
- 2 or more of the following sx for 3+ months with onset 6 months
- Soft, easily passed stools are not present without the use of medication
- Large amount of feces via digital exam = constipation
Factors Contributing to Constipation
- Storage of fecal contents to the point that water is resorbed.
- reduced colonic motility.
- prolonged gut transit time.
Constipation: Etiology
- Colonic transit problems
- Sedentary disorders
- Medical and psychogenic conditions
- Structural abnormalities/tumors
- Low water consumption
- Ignoring urge to defecate!
Symptoms of Constipation
- Highly subjective
- 24- hour dietary and fluid review
Constipation: Additional Findings
- Palpable mass Oral- poor detention and dehydration
- Rectal - screening for prolapse, impaction of hemroids
Constipation Diagnostics
- Dependant on symptomology.
Contipation: Differential Diagnosis
- R/ O Ileus
- Intra abdominal infections
- Megacolon
- Rule out systemic disease
Constipation: Management
- Increase fluids to 1.5 -2L a day and fiber 20-30g daily, but slowly
- Keep a stool diary
- initiate physical activity
- massage abdomen to stimulate persistalsis
- establish regular bowels
Pharmacologic Intervention
- Probiotics
- Stool softeners
- Osmotics like milk of magnesia
- Stimulants if needed
Diarrhea (Non-Infectious)
- Def= frequency of 3+ stools on daily basis and consistenty liquid content (stool weigh 250+g)
- Acute Diarrhea (less than 2 weeks/ usually by infection/ self resolving)
- Chronic Dia = more than month (autoimmune, endocrine & surgical issues)
Diarrhea Key Notes
- Look for fever & abd pain dehydration
- Pt normal stool
- Chart = when it started + frequency/ consistency
- Abrupt urgency, abd spams
- Bloody mucus in stool
Assessment (Diarrhea)
- recent illness/ trauma
- W loss. PMDX
Diarrhea Lab Work
stool for blood cbs (electrolyte etc)
DD (Dia)
CDIFF
- Stress
Dia Treatment
- antispdsmotic
Diverticular Disease
- Inflamed/uninflamed and bleeding
- Colonoscopy often is 1st indicator
Diverticulitis: Clinical Patterns.
- Most common if asymptomatic with multiple colonic diverticula
- D: may result in abscess/ fistula formation
- Hem -associated w/ R sided diverticulum or diverticula.
Diverticulosis
- Risk fact- red products/ obseity /smoking
- reduce risks = dietrary fiber, vegetarian
DDX of this Condition
- colitis, rectal pressure.
Diverticular Disease: Treatments
- Increase fiber & Exercise as able.
- If symptoms of colitis - clear liquids & antibiotics
Etiology of Dysphagia
- The swallowing disorder which can involve 1 or multiples in the normal process.
- Mild - severe; which can lead malnutrition/dehydration
- Oropharyngeal area is primary site.
Diagnosis and symptoms
- Neuromuscular / metabolic disorder / inf /tumor that leads to diff swallowing.
Clinical Presentation
- Loss of weight.
- Neuro damage: gait & muscle / stroke is important
Dysphagia: Treatment
- Diet changes & swallowing therapies like chin tuck rotation
- The goal is to assist swallow & reduce risk of infection,
- Head positioning (head tilt, chin tuck, head rotation to affected side, lie on side/elevation), and swallow maneuvers (supraglottic wallow, super supraglottic swallow, effortful swallow, Mendelsohn maneuver) are examples of swallowing strategies and therapies
- Diet changes can help patients manage with thickened or thin liquids.
- Gastrostomy tube placement may be necessary
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