FNP Abdominal - Primary Care
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| Types of evaluations to do with all pts presenting with abd pain | rectal, genital and pelvic evals
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| Viscera pain | originates in organs and is poorly localize, described as dull
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| parietal pain | originates in peritoneum and is well localized, described as sharp
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| Simple constipation comes from | decreased fiber in diet (recommended amount is 30g), high simple carbs and meat in diet, and suppressing urge to defecate
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| Disordered motility constipation comes from | usually seen in older adults and is caused by slowed transit time
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| Secondary constipation comes from | medications (including chronic laxative use), prolonged immobilization, and diseases of GI system like cancer.
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| Only med appropriate for long term use in constipation | bulking agent (psyllium)
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| Osmotic diarrhea comes from | injury to small intestine that results in malabsorption of nutrients; usually RESPONDS TO FASTING
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| Secretory diarrhea comes from | bacterial enterotoxins; produces watery stools that is UNRESPONSIVE TO FASTING
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| Typical GERD population | overweight with BMI over 25
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| Primary cause of GERD | transient relaxing of lower esophageal sphincter (LES), reflux occurs during abdominal straining, lifting, bending, or laying down
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| Affects of GERD while sleeping | decreased swallowing plus laying flat increases duration exposure to stomach acid at night
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| Barrett's Esophagus occurs when___ | repeated exposure of gastric contents that causes chronic inflammation. D/t chronic inflammation, increased blood flows to area and causes erosion. When erosion heals, normal cells are replaced w/ Barrett's epithelium; 40 fold increased risk of cancer
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| S&S of GERD (non obvious) | sour taste in mouth in AM, coughing, hoarseness, substernal CP, adult onset asthma, chronic cough, sore throat
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| Factors that make GERD worse | reclining after eating, eating big meal, alcohol, chocolate, caffeine, spicy/fatty food, nicotine
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| Diagnose GERD | esophageal pH testing; upper endoscopy with a biopsy can determine extent of barrett's esophagus
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| Who should get an EGD | pt's with heartburn, dysphagia, bleeding, anemia, weight loss, recurrent vomiting
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| Treatment for mild=mod GERD | lifestyle change x 4 wks, then H2 receptor agaonishs (Tagamet or Zantac) cheaper than PPI but will not heal esophagitis that is severe; try for 4 weeks
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| Treatment for mod-severe GERD | PPI (Prilosec, proton) QD or BID 30 min before breakfast; try for 6 weeks then refer to gastro entomologist
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| Small intestine infection manifests as | watery diarrhea
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| Large intestine infection manifests as | bloody diarrhea and abd pain
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| Food poisoning manifestation | N/V within 6 hours of exposure to pathogen
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| Viral abdominal infection manifestation | vomiting after 14 hrs of exposure
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| When to do a stool culture | pts w/ severe diarrhea, fever of 101.3, blood in stools, stools with leukocytes or lactoferrin = all of these indicate bacterial infection
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| when to check stool for parasites | diarrhea x 2 wks that is negative for leukocytes
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| Best diet for pts w/ diarrhea | fluids with sodium and boiled starches (pasta, rice, potato, wheat and oats) then advance as tolerated
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| When to give antibiotics for diarrhea | severe diarrhea, those with fever or leukocytes; bactrim DS or Cipro
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| Where do peptic ulcer disease occur | PUD is a generic name for both gastric and duodenal ulcers; most ulcers occur in duodenum
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| 3 biggest causes of peptic ulcer disease | H. pylori infection, chronically taking aspirin, or NSAIDS, & hypersecrection of acid
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| Classic sign of peptic ulcer disease | pain clusters and lasts for a few minutes then symptoms stop and begin again when food is present
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| Why is there nocturnal pain with Peptic ulcer disease | Acid is secreted due to stimulation of circadian rhythm
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| Duodenal ulcer relationship to food | less pain after eating
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| Gastric ulcer relationship to food | more pain when eating d/t more acid secretion
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| How to diagnose peptic ulcer disease | upper GI endoscopy
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| H. pylori affect on stomach | the stomach starts to produce more gastrin which leads to increase in acid which erodes stomach lining and results in an ulcer
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| Drug of choice for peptic ulcer disease | PPI - more effective than H2 antagonists, will heal 90% of duodenal ulcers in 4 weeks and 90% of gastric ulcers in 8 weeks
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| How to eradicate H. Pylori | 2 abx and PPI
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| Cholecystitis is usually from | gallstones (cholelithiasis)
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| Cholecycisistis without gallstones is__ | very serious disease usually resulting from trauma, burns, surgery or sepsis
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| Most common form of gallstone | cholesterol stones make up 75% as opposed to pigmented stones (makes up 25%
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| 6 F's of cholelithiasis | fat, female, forty (increased age), flatulence, fertile, fat intolerant
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| How gallstone are made__ | cholesterol only dissolves w/ bile salts and phospholipids (gets carried out in bile). When there's too much cholesterol for the bile it starts to crystallize
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| S&S of cholecystitis | N/V (especially after a fatty meal), pain in RUQ that may radiate to right shoulder or middle of back, abd rigidity, rebound tenderness, fever, positive Murphy's sign, mild jaundice (d/t edema of common bile duct)
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| Murphys sign | tests for cholecystitis; palpate 3 cm below costal margin (as if palpating for liver edge) have pt take deep breath in and when gall bladder slides down to meet fingers causes pt to have pain
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| What test is used to diagnose cholecystitis | ultrasound; may also have elevated liver enzymes and bilirubin levels
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| Treatment of cholecystitis | only treat if symptomatic, stop fatty foods, dissolution therapy (recurrence rate nearly 100%) lithotripsy, or surgery if candidate
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| Cause of acute pancreatitis | pancreatic enzymes get released into surrounding tissue and cause chemical burns in retroperitoneal spaces; usually occurs d/t passing of gallstone or alcoholism
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| S&S of acute pancreatitis | severe epigastric pain that may radiate straight through to back that is aggravated by any activity or laying down and is BETTER by sitting up straight and leaning forward, NO RIGIDITY OR REBOUND TENDERNESS, fever, tachycardia, tachypnic
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| , Test to diagnose acute pancreatitis | gold standard is serum amylase (may be elevated 3 times normal value which is 23-140) and elevated serum lipase; lab values increase in 24 hrs and return to normal in 3-7 days. Can get CT of abd and U/S IS MANDATORY to check for gallstones
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| What is used to check severity of acute pancreatitis | Ranson's criteria (>55, elevated WBC 16000, elevated glucose level 200, base deficit more than 4, LDH more than 350, AST more than 250, hematocrit drop 10 points, BUN rises 5 points, arterial PO2 less than 60, Calcium less than 8, fluid sequestration > 6
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| Treatment of mild acute pancreatitis | mild cases resolve on their own; fluids, NPO, NG tube for N/V, empiric abx, introduce clear liquids when pt is pain free, amylase and lipase is normal, and bowel sounds are heard
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| What is chronic pancreatitis | slow inflammatory process that causes irreversible fibrosis of pancreas and destroys and atrophies exocrine and endocrine gland tissue
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| 2 characteristic findings of chronic pancreatisit | inflammation and hyper secretion of protein (diets high in protein causes increased injury to pancreas in setting of alcoholism)
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| S&S of chronic pancreatitis | abd pain to epigastric or LUQ that may radiate to back. pain aggravated by food or alcohol, Pain may recede other symptoms by years, pain may also go away in 5-15 yrs which = burnout and calcification of gland, DM2, steatorrhea
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| Tests to diagnose chronic pancreatitis | bentiromide test (measures pancreatic secretions), elevated glucose, ERCP, CT or U/S
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| Management of chronic pancreatitis | stop alcohol use, pancreatic enzymes, analgesics, low fat diet,
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| Hep A transmission and longevity | Fecal to oral route, blood ; consuming contaminated water or food; is not a chronic condition and will not cause long term damage
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| Hep B transmission and longevity | high risk groups are gay males, IV drug users, those w/ multiple sex partners; transmitted by blood, semen, saliva, wound exudate, cervical secretions; 10% of pts will develop chronic hepatitis
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| Hep C transmission and longevity | transmitted by same things as Hep B, 70-90% of pts will develop chronic hepatitis
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| What makes each hepatitis different | caused by different organisms
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| Hep D transmission and longevity | occurs only in those with Hep B, transmitted by IV drug use
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| Hep E transmission and longevity | transmitted through fecal oral route but illness is self limiting
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| Chronic hepatitis characterized by | elevated AST and ALT levels for more than 6 months; can lead to cirrhosis
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| S&S of prodromal (beginning) phase of hepatitis | abrupt sx, N/V, abd pain, fever, fatigue
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| S&S of icteric phase (phase of illness) of hepatitis | jaundice, dark urine, light stools, gradual improvement of prodromal sx
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| S&S of convalescent phase of hepatitis | increased well being
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| Treatment of hepatitis | prevention and symptomatic relief
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| Cirrhosis is__ | end result of liver injury resulting fibrosis; is permanent; usually caused by alcohol
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| 3 consequences of alcohol abuse | 1. fatty liver = reversible; triglycerides accumulate in pockets of liver and causes inflammation (steatohepatitis) 2. alcoholic hep = d/t mod/severe alcohol use and can lead to cirrhosis even after abstinence 3. Alcoholic cirrhosis
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| S&S of cirrhosis | weakness, weight loss, fatigue, ascites, (menstrual abnormalities, impotence, gynecomastia d/t increased estrogen b/c liver canoes inactivate hormones), enlarged liver, dilated veins radiating around umbilicus, jaundiceD
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| Cirrhosis and portal HTN | causes caput medusa around umbilicus, ascites d/t increased pressure causing fluid to back up into abdomen
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| Diagnostic test for cirrhosis | liver biopsy
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| Management of cirrhosis | remain abstinent from alcohol, increase nutrition
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| What is abdominal hernia | protrusion of peritoneal sac through weakened abdominal wall; usually caused by force such as straining or heavy lifting
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| Males with abdominal hernias must be examined with___ | prostate exam to ensure that there isn't an obstruction causing increased abd pressure; doesn't matter the age of pt
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| Management of hernia | surgeon will decrease hernia and increase strength of abd wall.
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| Cause of appendicitis | It feels with food and ofttimes becomes obstructed causing infection
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| S&S o appendicitis | starts w/ pain near umbilicus but then focuses to RLQ, mild temp, may flex right knee up to relieve tension on appendix, rebound tenderness. If perforation pain will stop suddenly = emergency
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| Psoas sign | having pt raise right leg against gentle pressure, positive sign is pain = appendicitis
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| Obturator sign | flex right hip and knee then rotate internally (stretches obturator muscle), positive sign is pain = appendicitis
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| McBurney's sign | apply pressure to McBurney's point (halfway between umbilicus and ilium) positive is pain = appendicitis
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| Management of appendicitis | surgical
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| What 2 diseases make up inflammatory bowel disease | Ulcerative colitis and crohns disease
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| ulcerative colitis vs crohns disease | UC = only involves mucosal surface of colon Crohns = can affect all of GI from mouth to anus and any layer
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| Ulcerative colitis patho | cytokines and neutrophils are released during periods of inflammation and cause tissue damage. Ulcers form in eroded tissue and abscesses form in crypts. Abscesses turn necrotic. Mucosa swells and thickens = narrow lumen; fecal leukocytes ALWAYS present
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| Crohns patho | tissue damage occurs to areas of GI but skip certain parts = cobblestone appearance. Ulcerations form and fibrosis occurs and may cause bowl loops to stick to one another leading to obstruction and shortening of bowel
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| S&S inflammatory bowel disease | 4 plus loose stools a day that usually have blood in it, abd cramps relieved by defecating, mild fever, RLQ pain, sx worse when stressed, periods of exacerbation and remission
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| Tests to diagnose Ulcerative colitis | CT and sigmoidoscopy to see the extent of disease. Will get colonoscopy once treatment has begun to decrease risk of perforation
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| Tests to diagnose Crohns Disease | X-ray
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| Management of ulcerative colitis and crohns disease | goal in reduce inflammation (steroids), maintain nutritional status, and relieve Sx. no caffeine, raw fruit/vegetables. or foods high in fiber during acute attacks
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| Dx of Irritable bowel syndrome | must have 2 of the following: abd pain relieved by defecation (usually in LLQ), change in frequency of stool, change in appearance of stool
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| Irritable bowel syndrome and pt psyche | usually correlated with anxiety, depression, and precipitated by stressors
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| S&S of irritable bowel syndrome (besides the determining factors) | heightened sensation of bowel activity, abd issues begin 2 hrs after eating, sense of incomplete defecation, urgency to defecate
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| Management of irritable bowel syndrome | symptomatic; increase fiber regardless of constipation or diarrhea b/c it helps prevent excessive hydration and dehydration of stool,
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| S&S of abdominal obstruction | colicky pain that correlates to peristaltic waves, w/ N/V. May have constipation and distension. Bowel sounds are HIGH PITCHED AND HYPERACTIVE.
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| Diagnostic test of abdominal obstruction | abd xray
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| Management of bowel obstruction | surgery, NG tube to decompress
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| S&S of diverticulosis | pain LLQ, may be worse with eating and better with defecation or passing gas, may have diarrhea or constipation. When its inflamed = fever, chills, tachycardia
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| diagnostic test for diverticulosis | abd x-ray can help show perforation or peritonitis, CT w/ oral contrast will confirm diagnosis
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| Management of diverticulosis | if asymptomatic = high fiber diet, mild sx = abx & clear liquid diet; avoid constipation and straining
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| What are polyps | Benign form of colorectal cancer; if bigger than 7 mm should be removed
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| How polyps are classified | 1. hyperplastic (nonnenplastic) 2. adenomatous (neoplastic; most likely to turn into cancer) 3. submucosal (lipomas).
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| S&S of colorectal cancer | can be asymptomatic; melon, change in bowels, ribbonlike stool,
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| Diagnostic tests of colorectal cancer | colonoscopy w/ biopsy and barium enama
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| What are hemorrhoids | mass of dilated veins that have prolapsed; usually caused by straining
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| 1st degree of internal hemorrhoid | protrude into lumen of anal canal
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| 2nd degree of internal hemorrhoid | protrude beyond anal canal when defecating but reduce once completed stooling
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| 3rd degree of internal hemorrhoid | protrude beyond anal canal and must be manually reduced after bowel movement
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| 4th degree of internal hemorrhoid | protrude beyond anal canal and permanently prolapsed despite attempt to reduce.
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