MODULE 4 CMN 568 EXAM QUESTIONS WITH COMPLETE SOLUTIONS

Another word for indigestion dyspepsia = a symptom Main causes of dyspepsia stomach ulcer or acid reflux PUD or GERD Patients who should have an endoscopy due to dyspepsia? 60 yo younger if have alarm symptoms Patients who test negative for h. pylori or was treated for h. pylori and still have not improved after it was eradicated should be treated with what? trial empiric PPI increased visceral afferent sensitivity, gastric delayed emptying or impaired accommodation to food or psychosocial stressors = symptoms of ________________ ________________ functional dyspepsia Description of patient with functional dyspepsia younger pt. that reports a variety of abd and extra-gi complaints show signs of anxiety or dyspepsia, or have a hx of use of psychotropic medications Lifestyle changes to treat functional dyspepsia reduce or d/c ETOH & caffeine consume small, low fat meals keep food diary 1/3 patients with dyspepsia get relief from this? placebo pharmacologic agent for non-h. pylori dyspepsia pantoprazole 40 mg qd metoclopramide 5-10 mg TID no more than 3 mo. (black box warning, tardive dyskinesia) What is described as a vague intensely disagreeable sensation of sickness or queasiness and is distinguished from anorexia nausea What is described as often following nausea, as does retching. Distinguished from regurgitation, rumination vomiting What is an effortless reflux of liquid food or stomach contents regurgitation What is the chewing or swallowing of food thats regurgitated voluntarily after meals. rumination When might vomiting require hospitalization? severe acute vomiting- unable to eat, loosing gastric fluids leading to dehydration risk for hypokalemia and metabolic acidosis - very important to note in very young or old pt. Treatment for mild self-limiting nausea general measures- clear liquids, broth, teas soups. What could persistent hiccups signify. underlying illness, refer to either neuro or GI Causes of benign hiccuping gastric distention- drinking carbonated drinks, air swallowing, over eating, sudden changes in temps, heightened state of emotion Remedies that may help with benign self-limiting hiccups interrupting the respiratory cycle- valsalva maneuver, gasping, rebreathing into bag, sneezing Medication that can treat hiccuping phenothiazine - used to treat psych disorders infrequent stools, fewer than 3 in 1 week, hard stools, excessive straining or sense of incomplete evacuation describes what condition constipation First step in evaluating constipation? is to determine what is meant by constipation meaning asking the patient what their normal bowel habits are vs what is occurring now What condition is important to rule out due to new onset constipation Colonic lesions that obstruct fecal passage (neoplasms and strictures) Which patient should alert you to look further into constipation to rule out colonic lesions new onset constipation in pt. older than 50 yo, pt w/alarm symptoms or signs -hematochezia, weight loss, anemia, + fecal occult blood test (FOBT) or fecal immunochemical test (FIT) and in pt w/a family hx of colon ca or inflammatory bowel disease. refer How can you distinguish primary constipation from secondary with physical exam- digital rectal exam, assessing pelvic floor motion during simulated defecation - the ability to expect the finger additional tests that must be performed- CBC, electrolytes, glucose, TSH colonoscopy Once an emergency issue of constipation has been ruled out, how can constipation be managed. establishing a regular bowel regimen adequate fluids and fiber intake prescribe fiber supplements regular exercise med reconciliation- d/c meds that can cause constipation Probiotics- low efficacy- pts think it helps use of laxatives- only given intermittently and only if they do not respond to dietary measure Side effects of fiber supplements abd distension flatulence hesitate in prescribing for pt with opioid constipation and IBS Which medication given for constipation was traditionally used for colonic lavage prior to colonoscopy and does not cause flatulence. Onset of bowel evacuation is usually within 24 hrs after use. polyethylene glycol When does belching often occur after meals, comes from swallowing air, gum chewing, smoking, ingestion of carbonated beverages What is supra-gastric belching or true air swallowing that is behavioral disorder seen in pt with anxiety or psych disorders and what step should you take with these pt. chronic excessive belching. Refer to behavioral/speech therapist Causes of flatulence swallowed air and bacterial fermentation of undigested carbohydrate How can patients with complaints of flatulence be treated *provide them with a list of foods containing FODMAPS and refer to dietician *activated charcoal *avoid gum chewing and carbonated beverages ****assess for lactose intolerance by 2 week trial of lactose -free diet or by a hydrogen breath test an increase stool frequency of more than 3 bowel movements / day is what? diarrhea Questions to ask patient if they complain of diarrhea Must ask them their normal bowel pattern and nature of current symptoms What determines treatment of diarrhea is this an acute non-inflammatory diarrhea or acute inflammatory diarrhea Which type of diarrhea is described as fever and bloody diarrhea (dysentery) acute inflammatory diarrhea - caused by invasive or toxin producing bacteria (, shiga-toxin-producing _ Non-inflammatory diarrhea is described as? watery, non-bloody- caused by virus (giardia) or noninvasive bacteria (, staph aureus) periumbilical cramping suggesting small bowel source. diarrhea voluminous leading to dehydration Will there be fecal leukocytes with noninflammatory diarrhea No- there is no tissue invasion Symptoms of acute inflammatory diarrhea small volume diarrhea, left lower quadrant cramping, urgency, tenesmus, fever, bloody diarrhea, fecal leukocytes positive, When should diarrhea be evaluated as chronic diarrhea lasting longer than 14 days (except for c. diff pt) When should stool for analysis be sent to lab after evaluating for type of diarrhea, if persons at risk for spreading outbreak If diarrhea last greater than 7-14 days or worsens Differential diagnosis of patient with symptoms of infectious dysentery acute ulcerative colitis Treatment of diarrhea if pt does not have peritoneal signs of systemic toxicity start w/diet- increase oral fluids w/carbohydrates and electrolytes, rest the bowel (avoid high fiber food, caffeine, lactose), frequent feedings of tea, "flat" carbonated beverages, soft and easily digestible foods When should antidiarrheal agents not be used bloody diarrhea, systemic signs of illness, fever d/c if diarrhea getting worse despite tx Preferred antidiarrheal agent ? Loperamide- 4 mg initially, 2mg after each loose stool w/max 8 mg in 24 hr period Which medication do you give for traveler's diarrhea bismuth subsalicylate - also reduces vomiting associated w/viral enteritis Antibiotic of choice for diarrhea fluroquinalones x 1-3 days If patient is allergic to fluroquinalones what should you prescribe for infectious diarrhea trimethoprim-sulfamethazole or doxycycline Which antibiotics should NOT be given for diarrhea Macrolides or PCN due to widespread microbial resistance significant diarrhea in the absence of weight loss is not likely due to __________________________? malabsorption What is the time frame for chronic diarrhea 4 weeks exclude common causes before conducting extensive workup (meds, chronic infection, IBS) What should you do before performing extensive workup on pt with chronic diarrhea exclude common causes (meds, chronic infection, IBS) How can you differentiate if someone has osmotic diarrhea it resolves during fasting What is a common cause of diarrhea and should be considered in ALL patients w/chronic postprandial diarrhea carbohydrate malabsorption How is osmotic diarrheas diagnosed elimination trial x 2-3 wks. hydrogen breath test Lab work to obtain for most pt with chronic diarrhea CBC, Serum electrolytes, liver chemistries, Ca, Phos, albumin, TSH, Vit. A/D, INR, ESR, and C-reactive protein Patient who has chronic diarrhea lab work shows Anemia, what should you suspect. malabsorption syndrome inflammatory conditions Patient who has chronic diarrhea lab work shows hypoalbuminemia, what should you suspect malabsorption protein-losing enteropathies inflammatory conditions Lab work of pt with chronic diarrhea shows hyponatremia, nonanion gap metabolic acidosis, what should you suspect? Secretory diarrheas lab work of pt with chronic diarrhea shows increased ESR/C-Reactive protein, what should you suspect? inflammatory bowel disease If a pt presents with presence of nocturnal diarrhea, weight loss, anemia, or positive results of FOBT, what should be done? further evaluation