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NRNP 6560 Midterm exam

Surgery risk classes
Correct answer- Class 1: benefits outweigh risk, should be done
Class 2a: reasonable to perform
Class 2b: should be considered
Class 3: rarely appropriate
General rules for surgery: testing
Correct answer- ECG before surgery only if coronary disease, except when low risk
surgery
Stress test not indicated before surgery
Do not do prophylactic coronary revascularization
Meds before surgery
Correct answer- - Diabetic agents: Use insulin therapy to maintain glycemic goals(iii)
Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas,
and GLP-1 agonists
- Do not start aspirin before surgery
- Stop Warfarin 5 days before surgery
...

- Do not stop statin before surgery
- Do not start beta-blocker on day of surgery, but may continue
Assessment of surgical risk
Correct answer- - Unstable cardiac condition (recent MI, active angina, active HF,
uncontrolled HTN, severe valvular disease), concern with CAD, CHF
...

TNF-alpha plays a big role
- more women than men
- unknown cause
- Epstein Barr virus
Rheumatoid arthritis: Findings and diagnostics
Correct answer- - symmetric joint/ muscle pain, worse in the morning then gets better
- weakness, fatigue
- anorexia, weight loss
- generalized malaise
- swollen joints/ boggy feeling of joints with deformity of joints
- warm, red skin on affected joints
later:
- pleural effusions and pulmonary nodules
- inflammation of sclerea (scleritis)
- pericarditis, myocarditis
- splenomegaly (Felty's syndrome)
- anemia (hypochromic, microcytic) with low ferritin
- possibly: positive rheumatoid factor
- XR: joint swelling, later cortical and space thinning
- synovial fluid: yellow, thick with elevated WBC up to 100
...
Also
for prophylaxis
- Corticosteroids, if NSAIDS and colchicine not tolerated
- 24hr urine for uric acid
- Allopurinol after flare is over (100mg PO daily)
- Biological modifiers of disease (BMD): Pegloticase
...
Treat with
prophylaxis first
...
Tests in rheumatic disease: what, normal level, abnormal with
...

Normal: Titer 1
...
Tests in rheumatic disease: what, normal level, abnormal with
...
Women: 13-75 mg/dl
Increased with: inflammatory disease
Decreased with: RA, lupus, SS
The radioallergosorbent test (RAST)
...
Correct answer- measures presence/ increase antigen IgE
normal: 0
...
04 mg/dl
Increased with allergic reaction
Erythrocyte sedimentation rate (ESR)
...

Correct answer- rate at which RBC settle out of unclotted blood in 1 hr
Normal: men: 0-7mm/hr, women: 0 - 25 mm/hr
Increased with inflammation
CRP
...

Correct answer- C-reactive protein, a non-specific antigen antibody
Normal: trace to 6mg/ml
Increased with infection and inflammation, RA
...
Tests in rheumatic disease: what, normal level, abnormal with
...
antibody against IgG
...
Common sites: shoulder, elbow, wrist, hip,
knee, patella, ankle, spine
trauma, blunt force
neuromuscular disease
inflammatory joint disease, RA
Loose ligaments
Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital)
Findings and diagnostics subluxation
Correct answer- Pain over affected area
previous subluxation
swelling around joints
loss of ROM
XR, CT, MRI show subluxation
Increased WBC (stress response)
Management of subluxation
Correct answer- Early reduction, many spontaneously
immobilization (splint, sling)
PT
NSAIDS for pain/ swelling
Dislocation: what, cause

Correct answer- Complete displacement of bone end and position in joint
...
Positive with Meniscus injury
Lachman test: Hold upper and lower leg, around knee, stretch
...
Positive for herniated disk
...
If fracture
then may need surgery
...

T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone,
T3C: open fracture with arterial injury
- Incomplete or complete
- stress
- traumatic/ pathologic
- displaced/ non-displaced
Type of fracture lines Correct answer- Transverse
Spiral
Oblique
Comminuted
Logtitudinal
butterfly
segmental

impacted
Salter-Harris Fracture Classification Correct answer- Concerns growth plate
S: straight across growth plate
A: Above growth plate
L: BeLow growth plate
T: Through growth plate
R: ERaser of growth plate (Rammed)
Cause of fractures Correct answer- Trauma, tumor, osteoporosis, drugs (prednisone),
nutritional deficiency (Vit D), neuromuscular disorders
Findings and diagnostics of fractures Correct answer- Pain
History of traumatic event
Neuromuscular dystrophy: headache (autonomic dysreflexia)
Deformity of limp
Diminished/ absent pulses
ecchymosis and swelling
xr, always order anteroposterior and lateral
CT scan for pelvic and spinal fractures
MRI for suspected spinal cord injury
Mortise view (leg inward) for ankle to check talus bone
oblique films for humerus, femur, ankle
DEXA scan to determine degree of osteoporosis
Acute Fractures Management Correct answer- - ABC care (Airway, breathing,
circulation), musculoskeletal second survey
- fluid resuscitation
- early reduction of fracture
- cover open wounds
- surgical irrigation and debridement for open fracture
- Ab's: Cefazolin for gram pos
...
Most often in arms and legs (most compartments),
also abdomen
Men under age 35
stemming from fracture of tibia
stemming from splint, cast, scar
increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/
surgery, burn, bite
Compartment syndrome finding and diagnostics Correct answer- pain out of proportion

to injury
hx of trauma
paresthesia
heaviness in affected extremity
Six P's:
Pain on passive stretch
Paresthesia
Paralysis of affected limb (late finding)
Pulses, bounding first then pulseless later
Pallor of affected limb
Polar/ poikilothermia (ice cold limb)
Elevated WBC
Hyperkalemia (tissue necrosis)
CPK and LDH elevated
Myoglobin in urine
Elevated compartment pressure (normal 0-8)
Clinical diagnosis, MRI may confirm
Acute renal failure (due to myoglobinuria)
Compartment syndrome management Correct answer- Non surgical:
- limb at heart level (do not elevate)
- remove bandages/ immobilizers
- diuretic
- neurovascular checks
- CRRT/ dialysis to treat ARF
- intracompartmental pressure monitoring
Surgical:
- fasciotomy, with delayed closure of wounds (negative pressure wound vac)
- skin grafting
- amputation if septic from necrotic tissue
Restorative:
- functional splinting
- ROM
- early prostethic fitting post amputation
Low back pain - four major syndromes Correct answer- 1
...
Disk herniation
3
...
Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment
Specific findings for back pain Correct answer- - numbness
- saddle anesthesia (CA, mass)
- bowel, bladder dysfunction (emergency surgery)
- pain worse at rest (CA, tumor, infection)
- Discitis, epidural abcess (IV drug use)
- Decreased rom
- Radiculopathy (pain down leg), not with OA
- Crossover straight leg test: herniated disk
- back, buttock, leg pain when ambulating (neurogenic claudication with spinal
stenosis)
...
Causes: gradual to sudden weakness and inability to move/ lift legs,
bowel/ bladder incontinence, diminished sensation in legs: saddle
...

- Antiretroviral meds are approved for younger than 50yrs, so older pt's need close
monitoring
HIV etiology Correct answer- Africa/ Asia: heterosexually acquired
Western nations: men who have sex with men, iv drug user, congenital spread
Pathophysiology of HIV Correct answer- - HIV infects cells with CD4 receptor
(macrophages, Tcells)
...

When CD4 is less than 200 AIDS and viral load increases again, this immunodeficiency
- HIV is chronic and prgressive:
HIV - acute retroviral syndrome, symptoms Correct answer- fever, chills
fatigue
diffuse erythematous rash
HIV test may be negative, based on how long since infection
HIV viral load increased, CD4 within normal range
HIV - latent phase Correct answer- - asymptomatic
- may have persistent lymphadenopathy
- HIV load and CD4 load variable (ultimately HIV load high, CD4 low)
Symptomatic HIV disease Correct answer- Symptoms: fever, chills, diarrhea, weight
loss
- infections: candidiasis/ thrush (oral, mucocutaneous, vaginal), shingles (herpes
zoster), frequent bacterial infections
AIDS, definition and diagnosis Correct answer- acquired immune deficiency syndrome
CD4 low, below 500 and infection with opportunistic organism
Or:
CD4 below 200
Common oppertunistic organism in AIDS Correct answer- Pneumocystis jiroveci
Cryptosporidium
Candida albicans
Advanced HIV infection: definition, symptoms, prognosis Correct answer- CD4 below 50
Wasting, fevers, fatigue
Poor
HIV serologic testing Correct answer- - ELISA: test for antibodies, requires
seroconversion (neg to pos) which happens 3wks to 6mo after infection
- Rapid test: fast but not as sensitive as ELISA
- Confirmatory HIV test: Western blot test (HIV antibody test), used after pos with ELISA
HIV prevention Correct answer- - Condoms
- Male circumcision
- Pre-exposure prophylaxis (PrEP), for MSM sexually active men, adult iv drug users,

women with HIV pos partner who try to conceive
...
Also for HIV+
peope to for prevention of transmission
...

- Adherence is vital
- always assess drug- drug interactions/ medication reconciliation
- May make changes when CD4 exceeds evidence level
- check GFR/ creat/ BUN monthly for elderly on Tenofovir
- If deteriorating on ART (decline in CD4) then perform drug resistance testing and
revision of ART
Prophylaxis against opportunistic infections - HIV Correct answer- - TB: Isoniazid with
Pyridoxine
- Pneumocystis jiroveci (sudden rapid decline CD4): Trimethoprim- sulfamethoxazole
neb
...
Trimethoprim- sulfamethoxazole plus
pyrimethamine
...

- Mycobacterium avium
...
Zithromax or clarithromycin
Recommended vaccines for HIV Correct answer- - Hep B, if Hep B antigen neg
- Inactivated flu vaccine (assess viral load and do not give live vaccine)
- Hep A, liver disease risk, iv drug use, MSM
- Pneumococcal vaccine
- Tdap (instead of Td)
- Varcella Zoster for elderly
Test for HIV with following infections Correct answer- - candidiasis of esophagus/
trachea/ bronchi/ lungs
- extrapulm cryptococcus
- invasive cervical ca
- cryptosporidiosis with diarrhea
- CMV
- Herpes simplex lasting longer than 1mo

- Lymphoma brain, in younger than 60
- Kaposi sarcoma, younger than 60
- Mycobacterium TB
- Pneumocystis jiroveci pneumonia
- CD4 less than 200
Giant cell arteritis, definition and etiology Correct answer- Inflammation of the medium
and large arteries, often temporal artery or aorta, represents polymyalgia rheumatica
- adults older than 50
- more women than men
- most will also have polymyalgia rheumatica
- at risk for aortic aneurysm
polymylagia rheumatica Correct answer- Medical emergency because temporal arteritis
can lead to blindness and aortic arteritis can cause aortic occlusion
- pain, stiffness in shoulder and pelvic girdle region
- malaise weight loss, fever
- headache, jaw claudication, scalp tenderness, throat pain
Giant cell arteritis findings Correct answer- - headache
- jaw pain
- visual impairment
- throat pain
- arm claudication
- difficulty talking
- fever
- enlarged and tender temporal artery
- blindness
CT: arterial narrowing
WBC normal
ESR elevated
CRP elevated
Gold standard: biopsy of affected artery
Giant Cell arteritis treatment Correct answer- Prednisone, do not wait for biopsy
IV for 3 days when vision loss
Oral for 6 wks to 2mo
systemic lupus erythematosus (SLE) Correct answer- Chronic, inflammatory,
autoimmune disorder that affects multiple body systems, caused by trapping of
antibodies in capillary and visceral structures, destructing host cells
...
Panel reactive antibody
(PRA) measures preformed HLA and indicates a good match when elevated
...

Symptoms mostly failure of the organ (renal failure, liver failure, pulm effusions/
infiltrate, etc
...


- Started before or after transplant for up to 2 wks to delay first rejection episode
- maintenance for live of graft
- caution with conversion between generic and brand forms of cyclosporine
- Calcineurin inhibitors metabolized via cytochrome P450 enzyme, so may alter other
drig concentrations
- avoid grapefruit juice when on calcineurin inhibitors (may cause increase)
Common medical complications in organ transplantation Correct answer- HTN
Calcium channel blockers often used to treat
...
Avoid
hypotension in kidney recipient
...
Increases risk for graft loss
...

Renal insufficiency
Nephrotoxicity from meds (Calcineurin inhibitors)
...
Optimize
pharm cholesterol management
Bone disease
Osteoporosis common, related to corticosteroid
...
Minimze corticosteroid use, give calcium
Malignancy
Increased incidence of lymphoma, skin ca, Kaposi's sarcoma
...
Treat: minimize immunosuppression,
start radiation
...

Calcineurin inhibitors: which, indication, adverse effects Correct answer- Tacrolimus
Cyclosporine
Prophylaxis of rejection
T: tremor, renal dysfunction, hyperglycemia
C: tremor, renal dysfunction, htn, hirsutism, gingival hyperplasia
mTOR inhibitors: which, indication, adverse effects Correct answer- Sirolimus
Everolimus
Prophylaxis of rejection
S: edema, rash, hyperlipidemia, abd pain, nausea, diarrrhea, trombocytopenia, fever
E: htn, edema, rash, hld, thrombicytopenia, hyperglycemia, elevated LFT's, fatigue,
fever
Corticosteroids: which, indication, adverse effects Correct answer- Prednisone
Solumedrol
P: Prophylaxis of rejection
S: Induction, treatment and prophylaxis of rejection
Fluid retention, hyperglycemia, impaired wound healing, peptic ulcer
Infections in organ recipients: general thoughts and types Correct answer- - infections
are leading cause of death
- Increased risk 6 mo post transplant
- fever and wbc count not as pronounced because of immunosuppressive meds
Viral:
CMV, cause of morbidity and rejection
Requires frequent monitoring
Prophylaxis with ganciclovir is recommended

Fungal:
Candida in post-liver, Aspergillus in post-lung
Oral fluconazole for fungal prophylaxis or Trimethroprim-sulfamethoxazole (bactrim) for
pneumocystis prophylaxis
Bacterial:
Most common infections
Intra-abd infections for liver, pancreas and intestinal transplant
Pneumonia for heart and lung transplants
UTI for renal and pancreas transplant
organ recipient and vaccinations Correct answer- - Should receive flu vaccine, but not
live vaccine
- Up to date on vaccines before transplantation
- no live vaccines and avoid household members post live vaccine vaccination
kidney transplantation, incidence and complications Correct answer- ESRD, creat clear
less than 15ml/min
Surgical:
Graft thrombosis, 2-3 days post-op
...

Diagnosis with renal us
...

Urine leak:
2-3 days post-op from surgical technique or necrosis
...
Take back to surgery or foley/ nephrostomy tube
...

Diagnosis with aspiration (protein containing fluid)
...

Bleeding
Uretral obstruction:
decline in graft function from blood clot, surgical technique, rejection, or infection
...
Treat with nephrostomy tube, surgical correction
Delayed graft function:
May need dialysis and modification of immunosuppressive regimen
Rejection
Infection: UTI
Liver transplantation, incidence and complications Correct answer- Chronic hepatitis,
alcoholic liver disease, hepatocellular carcinoma, ESLD
Surgical:
Hepatic Artery Thrombosis
...
Diagnosis with US or CT
...
Poor prognosis
Rejection
Infection
Biliary cast syndrome (bile duct strictyure and clogging)
Recurrence of disease
Lung transplantation, incidence and complications Correct answer- Pulm HTN, CF,

COPD, sarcoidosis
...

Surgical:
Bronchial anastomotic complications: ischemia and necrosis of anastomosis
...

Bleeding
Ischemia/ reperfusion therapy
72 hrs post op
...
Causes alveolar damage, pulm edema,
hypoexemia
...

Sepsis
Bronchiolitis obliterans syndrome
From chronic rejection causing exertional dysonea and cough with decreased FEV1
...

Rejection
...
Accelerated form of CAD causing HF, ventricular arrythmia's,
death
...
Within first few mo
...
Surgical
correction
...
Peritonitis
Rejection
Intestinal transplantation, incidence and complications Correct answer- Necrotizing
enterocolitis, Chrohn's, stenosis of small bowel
Surgical:
Bleeding
Bowel obstruction
Ascites
Perforation
Biliary leaks
Hypermotility
In early posttransplant phase
...

Rejection
Infection
Hepatitis Correct answer- Inflammation of the liver, caused by Hep A, C, D, E as RNA
and B as DNA

Hepatitis A: what, etiology, findings, management Correct answer- Viral Hepatitis
Spread by fecal-oral route
...

-Pos Immunoglobulin IgM anti-HAV - first week of disease, disappears after 3 - 6 mo
...
Neg: no infect in last 12mo
- ALT AST elevated
- Pos IgG anti-HAV
...
If neg: no infection
...
Low protein, no fatty foods, high carb
- no alcohol
- hospital for encephalopathy or coagulopathy
- antiemetics
Vaccine: Hep A for children 1 year and people increased risk
Hepatitis B: what, etiology, findings, management Correct answer- Viral hepatitis
Bloodborne, saliva, semen, vaginal secretions, so transmitted through sex, drug use,
piercing, tattoo, blood products
- Pos Hep B surface antigen or Hep B core antigen, in acute infection
- Total Hep core antigen can indicate past exposure
- Hep B surface antibody after clearance of Hep B surface antigen or vaccination, which
means: recovery, noninfectious, protection from current infection
- pos Hep B e-antigen: acute or chronic infection
- Hep B e-antibody means success from antiviral therapy (e-antigen has become eantibody)
- Treat if liver-related mortality risk in next 5-10yrs is high and chance of viral
suppression high
- Antiviral therapy:
- Peginterferon alpha, weekly/ 48 wks (many side effects)
- Entecavir, PO daily, renal adjustment
- Tenofovir, PO daily
Vaccination: Not live, in 3 doses
Diagnose Hep A Correct answer- Oral transmission
Increased ALT over AST
IgM (IgM anti HAV)
Diagnose Hep B Correct answer- Intravenous transmission
Increased ALT over AST
pos for the surface if vaccinated (IgM surface antigen)
pos for the core and the surface if infection (Cor IgM antigen and IgM surface antigen)
Diagnose Hep C Correct answer- Intravenous transmission, tattoo's, razors, sex
partners
Increased ALT over AST
Anti HCV Antibody
HCV RNA
Diagnose alcoholic liver failure Correct answer- Alcohol use
AST higher than ALT
Diagnosis of exclusion
Ischemic liver failure Correct answer- AST and ALT very high (in the 1000)
shock state
Hepatitis C: what, etiology, findings, management Correct answer- Viral Hepatitis
Blood-borne
...

Common, but often asymptomatic
...


- Pos Anti HCV antibody
...
If neg, then unlikely
...
Detects
virus not antibodies
...
Give for 48wks
...
Add Boceprevir for genotype 1
...
Screen one time based on age, born between '45 and '65
Hepatitis D Correct answer- RNA virus that can only cause infection with Hep B
Prevented with Hep B vaccin
Hepatitis E: what, etiology, findings, management Correct answer- acute infection, no
chronic
ingestion from fecal matter, poor sanitation
Like HAV
Mortality higher in pregnant women
No vaccin
Hepatitis G Correct answer- Common in drug users, transmitted percutanously
Viral hepatitis risk factors Correct answer- Health care providers
hemodialysis
blood products
IV drug use
sex men with men
underdeveloped countries
piercing/ tattoo
Viral Hepatitis Symptoms/ diagnostics Correct answer- - Prodromal phase:
malaise, arthralgia, upper resp symptoms, anorexia, n/v, diarrhea/ constipation, skin
rashes, aversion to smoking (HBV), mild upper quadrant abd pain
- Icteric phase:
jaundice, no icterus, dark urine
Physical:
tender hepatomegaly, splenomegaly, cervical lymphadenopathy, rash (HBV), arthritis
Diagnostics:
WBC wnl or low
Proteinuria
Bilirubinuria
ALT and AST elevated (greater than 500)
Bilirubin elevated
PT normal, if elevated: severe liver damage
Autoimmune hepatitis: what, etiology, findings, management Correct answerunresolving inflammation of liver with
unknown cause
More women than men
- Abnormal serum globulins and presence of autoantibodies
- Abnormal serum aminotransferases
Prednisone monotherapy, induction and maintenance
Prednisone with azathioprine, induction and maintenance
May need liver transplant
Diagnose autoimmune hepatitis Correct answer- Young women
ALT higher than AST
Will have anti smooth muscle antibody
nonalcoholic steatohepatitis (NASH): what, etiology, findings, management Correct
answer- Nonalcoholic fatty liver disease
...
No fibrosis (scarring of liver which can lead to
cirrhosis)
...
455: no fibrosis
greater than 0
...

Tired, itching woman
Positive anti mitochondrial antibodies (liver biopsy)
Alk phos elevated
Portal granumolas (intrahepatic biliary ducts destruction)
Increased cholesterol
Bilirubin up late in disease
Diagnosing Primary sclerosing cholangitis Correct answer- Intra en extra hepatic flow is
blocked
...
Often leads to cirrhosis
...

Kayser-Fleisher rings in eyes
Increased ALT and AST
Low cerumplasmin (copper sucked up)
Diagnose alpha1 -antitrypsin deficiency Correct answer- COPD (later in life, while early
smoker), asthma
Pas + granules in liver
alpha1 antitrypsin level pos
Alcoholic liver disease: etiology, findings, management Correct answer- Most common
cause of cirrhosis
Women twice as sensitive to alcohol toxicity then men
Binge drinking
High mortality rate
Diagnosis on report of alcohol intake, evidence of liver disease, lab abnormalities
AST and ALT often high than 2
Score for mortality: Maddreys' score
- Abstinence
- MDF score greater than 32: prednisone for 4 wks
- May require liver transplant
Wilson's: what, etiology, findings, management Correct answer- Familial autosomal
recessive disease with neurological symptoms, by chronic liver disease, leading to
cirrhosis
...
Caused by a lack of a certain gene that causes diminished
excretion of copper into bile
...

Any pt between 3 and 55 with liver disease without clear cause
...

Liver biopsy to measure copper
high bilirubin to alkaline phosphatase ratio greater than 2
D-penicillamine, initial ansd maintenance
Zinc, blocks absorption of copper
Avoid food and water with copper
May need liver transplant when cirrhosis is present
Family screening
Fulminant liver failure/ acute liver failure: what, etiology Correct answer- - sudden
impairment of liver cell function

- Hep A, B, C, D, E
- CMV, Epstein-Barr
- drug-induced (Tylenol)
- Toxins (mushrooms)
- Vascular (heat stroke)
- other liver disorders
Acute liver failure: findings, management Correct answer- Weakness, fatigue
weightloss, n/v, abd pain
Change in bowel pattern
- Check BMP, ABG, lactate, toxicology screen, acetaminophen screen, Hep panel, PT/
INR
- Treat specific etiology:
charcoal for acetaminophen and N-acetylcysteine)
Supportive for Hep A and E
Antiviral for Hep B
Test for Wilson
- ICU management: watch for cerebral edema, hyperventilate if present, mannitol
...
3, encephalopatic,
INR greater than 6
...
4
- Non acetaminophen: liver transplant if INR greater than 6
...

Model for End-Stage Liver Disease (MELD): to determine severity of liver disease,
based on bilirubin, INR, and creat
...

Cholestyramine or Colestipol for pruritis
- Fluid/ electrolytes: ascites, hypokalemia, hyponatremia, hypernatremia, hypoglycemia
...

Water restriction for hyponatremia
...

Low sodium diet, fluid restriction, and diuretics, potential paracentesis (give albumin) for
ascites
...

- GI: GI bleeding, abd pain, varices, n/v
- Neuro: hepatic encephalopathy
...
Limit protein
...

- Resp: Hyperventilation, hypoxemia
Mech ventilation possible
...


May need dialysis
...
Give Vit K subq for PT greater than 14 and INR greater than 2
- ALT and AST elevated
- ammonia elevated
Liver labs Correct answer- Cytotoxic:
AST (made in liver): marker for hepatic inflammation
...
Will go
up in recent liver injury
...

ALT: marker for hepatic inflammation
...
Will go up in recent
liver injury
...

Albumin (made in liver): low means chronic liver injury
PT: prothrombin time
...

Clotting time
...
Low Vit K and coumadin can
also increase prothrombin time
...
Often with gallstones (cholelithiasis)
...
From cholesterol
...
With unexplained fever or after multiple trauma and poor
oral intake
-bacteria
- cancer
- risk factors: obesity, pregnanvy, sedentary lifestyle, low fiber diet, female, older age,
high cholesterol
mild: no organ dysfunction
moderate: leukocytosis, complaints longer than 72 hours, local inflammation
Severe: organ dysfunction
Cholecystitis: findings/ diagnostics Correct answer- - asymptomatic, devloping into
bloating/ abd pain
- biliary colic: intense epigastric pain radiating to shoulder/ back
- N/V
- anorexia
- elevated temp
- pos Murphy's (pain on inspiration with fingers under right rib cage)
- palbable galbladder
- jaundice
- right upper quadrant pain, fever, leukocytosis, guarding with severe inflammation
- leulocytosis
- elevated bili
- Increased alanine transaminase, aspartate transaminase, lactate dehydrogenase,
alkaline phosphatase
- elevated amylase
- ecg and xr chest to rule out mi or pneumonia
- US: best study for diagnosiing gallstones
- ERCP: assess biliary and pancreatic ducts
- Graded by severity:
Cholecystitis: management Correct answer- NPO
IV fluids
Pain control (NSAIDS)

AB's iv (third gen cephalosporin, zosyn, merrem)
Surgery: Cholecystectomy
ERCP for stones in bileduct
Ursodiol for small stones (smaller than 2cm)
Large bile duct obstruction Correct answer- Pain/ fever
Alk phos elevated
Total bili elevated
Cholestatic labs Correct answer- - Alkaline phosphatase: increased with cholestasis
(flow from liver is blocked)), pregnancy, bone growth/ disease (Paget's)
- GGT: increased with cholestasis but not bone disease, may be elevated with alcohol
- indirect bilirubin: increased with breakdown of blood (DIC), Gilbert's
- direct bilirubin: more than 50% (compared to total) with blocked intrahepatic or
extrahepatic duct (bileduct stone, pancreatic tumor)
- bilirubinuria: blocked flow from liver
acute pancreatitis: what and etiology Correct answer- inflammation of pancreas
Alcoholism
Gallstones
Smoking
Traumatic or hereditary
Infectious (CMV)
Meds: Sulfa drugs, thiazide diuretics, Lasix, Corticosteroids, Depakote, Opioids
Acute pancreatitis findings/ diagnostics Correct answer- - Epigastric abd pain, abrupt,
worse with walking or supine, better with knee to chest, leaning forward
- N/V
- hypoactive bowelsounds
- tachycardia, hypotension
- jaundice
- ascites
- Elevated lipase and amylase
- elevated urine amylase
- elevated trypsin levels
- leukocytosis
- Bili elevated
- Hypocalcemia if severe disease
- Low albumin
- xr abdomen: ileus, pancreatic calcifications, gallstones
- CT abdomen preferred over US, and MRI over CT
Acute pancreatitis management Correct answer- - IV hydration - Fluid therapy to
prevent hypovolemia and shock: LR or NS with 20 K at 75- 100 ml/hr
- May need plasma, RBC, albumin
- Pain control - Morphine, Fentanyl
- AB's, not prophylactically, only when septic or biliary stones
...
More thna seven: 100%
...
Intestine next to obstruction fills with gas and fluid which is not absorbed
and causes distention
...
Which triggers
intestine to release even more fluid and cause distention
...

- Adhesions
- Hernia's
- Volvulus - twisting of bowel on itself
- strictures: crohn's, radiation, ischemia
- Intussusception
- impaction
- foreign body
Small bowel obstruction: findings/ diagnostics Correct answer- - periumbilical cramping
- upper abd pain with profuse vomiting: high bowel obstruction
- cramping, periumbilical pain with episodic pain: middle bowel obstruction
- Constipation
- High pitched tinkling bowel sounds, first
...

- Dehydration signs
- leukocytosis
- Elevated Hgb and Hct
- metabolic acidosis
- electrolyte imbalances
- supine and upright abd xr: air-fluid levels ladderlike, free air reqiures immediate
surgery
- US abd: dilated loops of bowel filled with fluids
...

- Can use barium but CT better (also better than xr)
Small bowel obstruction: management Correct answer- - NPO
- Fluid and electrolyte replacement
- NG to LIS
- bld
...
Can distinguish between complete and partial obstruction,
ileus, and small bowel

Large bowel obstruction: management Correct answer- Fluid resuscitation
AB's
NG for vomiting
Surgery
...
60% mortality
...
platelets for low
platelets
...
Gastric ulcer: loss of surface epithelium
...
From NSAID and aspirin use
...
Peak incidence: 55-70yrs
...
Pylori present in most duodenal ulcers
...
pylori, gastric acid, pepsin, bile, meds (NSAIDS/ aspirin)
...
Relieved by
food ingestion
...
Not relieved by food
...
Nausea
...
Midline or left of midline
...
Hematesis or melena with bleeding
ulcers
...
Pylori testing
- CBC: anemia?
- Leukocytosis: perforation or penetration
- elevated amylase: penetration into pancreas
- Upper GI barium studies: after 8-12wks for established ulcer to distinguish benign from
malignant
- Endoscopy: Procedure of choice for diagnosis of duodenal and gastric ulcer
...
Pylori, and inflammatory disorders, and can perform
electrocautery
H
...
Pylori:
- Endoscopic biopsy (gold standard)
- urea breath test (pos is H
...
Pylori antibody test (can also mean previous infection)
- fecal antigen H
...


- Gastric Outlet obstruction
Symptoms: early satiety, n/v, epigastric pain unrelieved by food/antacids, succussion
splash, NG foulsmelling large amount
Perform upper GI endoscopy and saline test at 72hrs (check residual)
Treat: Treat hypokalemia, if present because of N/V, Start H2 blocker (pepcid), surgery
Meds used for PUD Correct answer- - H2 blocker (Famotidine, Ranitidine), decreases
acid secretion, symptom relief in 2 wks, healing in 6wks for duodenal and 8 wks for
gastric (Cimetidine raises theophylline and warfarin levels)
- PPIs (Omeprazole (gastric), Pantoprazole (duodenal), Esomeprazole (gastric),
suppresses gastric acid secretion
...
Check
gastrin after 6mo and may cause low Vit B12, Ca, low iron and C Diff, hip #, pneumonia
- Sucralfate
...
Can cause constipation
...

- Cytotec
...
Can cause diarrhea
...

- Antacids
...
Can cause diarrhea, hypermagnesemia,
hypophosphatemia
H
...
May cause reflux esophagitis
...
Electrode
PH probe aboev LES
-Barium swallow test (as screening tool and rule out inflammation, ulcers, and strictures)
-Endoscopy (for diagnosis and possible biopsy and dilation of stricture)
-Bernstein test (infusion of acid and ns)
GERD management Correct answer- Phase 1:

Elevate head
No exercise before bed
No large meals before bed
Avoid chocolate, fats, alcohol, mint, spicy, citrus, coffee, tomato juice
Reduce weight
Stop smoking
Avoid aggravating meds
Use antacids PRN (after meals and bedtime) and over the counter H2 blocker
(ranitidine/ famotidine) for 8 - 10 wks
Phase 2:
Continue phase 1
...
5
ESR 20-30
HR 90 - 100
Hct 30 - 40
stool #: 4 - 6/ day
temp: 99 - 100F
weight loss: 1 - 10%
Severe:
albumin less than 3
ESR more than 3
HR higher than 100
Hct less than 30
stool #: more than 6/ day
temp: above 100F
weight loss: greater than 10%
Ulcerative Colitis treatment Correct answer- Mild/ moderate:
Firstline: oral or topical (enema) sulfasalazine or corticosteroids
Oral prednisone if not responsive to tx or systemically ill
Mild/ moderate extensive:
Cornerstone: Sulfasalazine
First line: oral sulfasalazine
...
Give
Folate with it
...

INfliximab for pt's refractory to that
Severe:
hospitalize
NPO

no opioids/ anticholinergics
nlood transfusion if needed
7-10 days corticosteroid IV (methylprednisolone)
Infliximab
Immunomodulators: purinethol, imuran, cyclosporine (maintenance of remission)
If refractory: colectomy
Toxic megacolon: surgical decompression, ab's, colectomy
Surgery for:
toxic megacolon
refractory disease
perforation
hemorrhage
carcinoma
Toxic megacolon: symptoms and treatment Correct answer- Symptoms:
rapid UC progression
fever
anemia
xr abd to detect megacolon
ab's (cover gram - and aneorobes)
NG
surgery within 72hrs if failing to respond to tx
Crohn's Disease Correct answer- Inflammation and ulceration, stricturing, fistula,
abscess across entire colon
...
At greater risk for developing colon ca, lymphoma, and small bowel
adenoca
...
4 - 4
...

IV corticosteroids
IV cyclosporine/ methotrexate (immunomodulator)
Maintenance:
no corticosteroid
Azathioprine (2-3mg/kg/day) or inflixinab (immunomodulator and anti TNF monocloiinal
antibody)

Diet: well-balanced, may need supplemental enteral therapy during active disease
IBD drugs: Correct answer- Aminosalicylates:
Sulfasalazine, non sulfa: mesalamine
...

May cause N/V and folate malabsorption
...

May cause infusion related reactions: fever, pruritis, chest pain, hypotension, htn,
infections/ sepsis
...

Secondary: peritonitis with cause that can be operated on, such as infection, abdominal
trauma, perforation from appendicitis, colitis, PUD, diverticulitis, pancreatitis,
cholecystitis
...
Most sensitive test
...
For 10 days
...
No cipro
...

Caused by: fecalith (fecal stone), inflammation, intestinal worms, strictures, tumors
...

Appendicitis findings and diagnostics Correct answer- Abd pain: periumbilical first, then
right lower quadrant pain (McBurney's point)
Rovsing's sign: pain rlq when touched llq
Psoas sign: pain with extension of right hip
Obturator sign: pain with internal rotation right hip
Anorexia
n/v
constipation
low grade fever
motionless, right thigh up
guarding rlq
Moderate leukocytosis
UA: elevated spec gravity, hematuria, pyuria, albuminuria
Ultra sound: very sensitive
CT to detect: perforation, periappendiceal abscess
Appendicitis Treatment Correct answer- Mainstay treatment: surgery
IV fluids/ correct electrolytes
AB: Cefoxitin 1 - 2 gr
Tx for gangrenous/ perforated appendicitis:
- mild/ moderate severity: one AB or Cefazolin/ Ceftraixone/ Cipro/ Levaquin with Flagyl
- high risk/ severity (immunocompromised, old): Meropenem, Zosyn or Cefepime/ Cipro/
Levaquin with Flagyl
...

Tenderness = appendicitis



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