1
Q
Causes of RUQ pain related to the gall bladder
A
- Cholelithiasis
- Acute cholecystitis
- Acute cholangitis
- Biliary colic
- Sphincter of odi dysfunction
2
Q
biliary colic symptoms
A
- biggest thing to remember is that is plateaus at an hour, worse in first 30 minutes. will have a benign abdominal exam
3
Q
Acute cholecystitis symptoms?
A
Prolonged (>4 to 6 hours) RUQ or epigastric pain, fever. Patients will have abdominal guarding and Murphy’s sign
4
Q
acute cholangitis symptoms
A
Fever, jaundice, RUQ pain
5
Q
Hepatic causes of RUQ pain?
A
- Acute hepatitis
- Fitz-hugh syndrome
- portal vein thrombosis
- liver abscess
- budd-chiari syndrome
6
Q
Acute hepatitis symptoms?
A
RUQ pain with fatigue, malaise, nausea, vomiting, and anorexia. Patients may also have jaundice, dark urine, and light-colored stools
7
Q
Causes of epigastric pain?
A
- Acute MI
- acute pancreatitis
- chronic pancreatitis
- PUD
- GERD
- Gastritis
8
Q
Causes of lower abdominal pain?
A
- Appendicitis
- Diverticulitis
- Nephrolithiasis
- pyelonephritis
- cystitis
9
Q
A cbc for a patent with appendicitis will show what to support the diagnoses?
A
Neutrophilia
10
Q
Imaging of choice for appendicitis?
A
ultrasound, CT if you have too
11
Q
Labs for cholecystitis will show what?
A
elevated ALK-P, GGT, bilirubin and WBC
12
Q
First imaging option for cholecystitis? if this is inconclusive then move on to what?
A
- Ultrasound
2. HIDA
13
Q
An ultrasound suspicious of cholecystitis will show what?
A
- Gall bladder wall >3mm
- Pericholecystic fluid
- gallstones
14
Q
Whats the gold standard for diagnosing choledocholithiasis?
A
ERCP and its therapeutic
15
Q
A CT is an option for diagnosing gall bladder issues but it is more sensitive for what?
A
- Perforation
- Abscess
- Pancreatitis
16
Q
What are some causes of acute hepatitis?
A
Viral hepatitides (e.g., HAV, HCV, and HBV) Parasites (e.g., toxoplasmosis) Alcohol Drug-induced (e.g., acetaminophen) Autoimmune hepatitis Steatohepatitis Metabolic disease
17
Q
What are two things that in a question should make you suspicious for acute hepatitis?
A
- Recent travel
2. Sudden jaundice
18
Q
If the ratio of AST:ALT >2 what should you suspect?
A
alcoholic hepatitis
19
Q
With acute hepatitis not related to alcohol which is usually more elevated AST or ALT
A
ALT
20
Q
What imaging would be a good first choice in someone suspected of acute hepatitis?
A
Ultrasound
21
Q
A CBC in someone with viral acute hepatitis will show what in terms of WBC and lymphocytes?
A
- Elevated WBCs
2. Atypical lymphocytosis
22
Q
Anti-HBc IgM Anti-HBc IgG HBsAg Anti-HBs Interpretation?
+ - + -
A
Acute Hep B infection
23
Q
Anti-HBc IgM Anti-HBc IgG HBsAg Anti-HBs Interpretation?
- - + -
A
early acute HBV
24
Q
Anti-HBc IgM (-) Anti-HBc IgG (+) HBsAg (-) Anti-HBs (+) Interpretation?
A
resolved acute HBV/ immune due to exposer
25
Anti-HBc IgM (-) Anti-HBc IgG (-) HBsAg (-) Anti-HBs (+) Interpretation?
immunity from vaccine
26
Anti-HBc IgM (-) Anti-HBc IgG (+) HBsAg (+) Anti-HBs (-) Interpretation ?
chronic HBV
27
Medication Tx for alcoholic hepatitis?
pentoxifylline and/or corticosteroids
28
When do you use antiviral therapy for hepatitis?
indicated for severe acute hep B
29
Common causes for acute pancreatitis?
mnemonic GET SMASHHED
1. Gall stones
2. ethanol
3. trauma
4. steroids
5. Mumps
6. scorpion sting
7. hypercalcemia
8. hyperlipidemia
9. ERCP
10. Drugs
30
Imaging of choice for diagnosing Pancreatitis
abdominal CT to make sure its not necrotic pancreatitis
31
What is the most sensitive diagnostic choice for chronic pancreatitis?
ERCP
32
What is a complication with pancreatitis?
pancreatic pseudocyst
33
What is the Tx for anorectal abscess?
surgical incision and drainage, stool softeners, high fiber diet
34
Tx for anorectal fistula
fistula must be treat surgically
35
signs that someone has an anal fissure
1. tearing rectal pain when pooping
| 2. bright red blood on toilet paper
36
Tx for anal fissures? backup tx if first line fails?
1. Sitz baths, increase dietary fiber, and water maybe a stool softener here and there (should heal in 6 weeks)
2. botulinum toxin A if failed conservative therapy
37
What is the order in which symptoms for appendicitis flow.
1. periumbilical pain
2. nausea/vomiting
3. anorexia
4. right lower quadrant pain
38
What GI issues can anorexia be linked to?
1. Gastric ulcer
2. Duodenal ulcer
3. Gastric cancer
4. Lower GI bleed
5. pancreatic carcinoma
6. thyroid disease
39
What are the symptoms of gastric cancer?
use the mnemonic WEAPON
1. weight loss
2. emesis
3. anorexia
4. pain/epigastric
5. obstruction
6. nausea
40
If someone complains of epigastric pain a couple hours after eating which type of ulcer do they likely have?
duodenal ulcer
41
If you read "painless jaundice" what should you immediately think of?
pancreatic cancer
42
New onset of constipation in a pt over 50 should make you think of what?
colorectal cancer
43
A patient with DM II comes in complaining of abdominal pain and fullness after eating only small amounts of food. What could they have and what in their history points you in that direction?
Could be gastroparesis, their diabetes causes nerve damage and they could have damage to the vagus nerve which would explain their symptoms
44
What is charcots triad and what does it pertain to?
1. RUQ pain, jaundice, fever
| 2. Applies to cholangitis
45
What is reynolds pentad? and what does this signify?
This is charcots triad so (RUQ pain, Jaundice, Fever) plus altered mental state and hypotension
guess it just signifies a worse case of cholangitis
46
What is your initial imaging of choice for cholangitis? what is the best?
1. Ultrasound
| 2. ERCP
47
What is the tx for cholangitis?
1. Acutely you need removal of stones (ERCP) , fluids, antibiotic (cipro and metro) and analgesics
2. Once they are stable you remove the gall bladder
48
What is primary sclerosing cholangitis associated with?
1. IBD
2. pancreatic cancer
3. colorectal cancer
4. chlangiocarcinoma
49
How would you describe cirrhosis of the liver to a patient?
Can say it is when your liver tissue become fibrous and stiff along with having numerous nodules all of which effect its function.
50
Which lab value in cirrhosis is usually more elevated AST or ALT?
AST
51
What lab should be monitored in patients with cirrhosis because of their increased chance for hepatic carcinoma?
AFP
these pts have a 10-25% greater chance of getting cancer
52
What is the most common cause of cirrhosis? what is the second most common cause?
1. Alcohol
| 2. Hep B and C
53
What does this triad represent abdominal pain, ascites and hepatomegaly?
Hepatic vein thromboses aka budd chiari syndrome
54
What labs should you monitor in someone with cirrhosis and how often?
CBC, LFTs, Coag panel, electrolytes, renal function
Should be done ever 3-4 months
55
What kind of imaging should you perform periodically for someone with cirrhosis and how periodically
abdominal ultrasound every 6-12 months looking for hepatocellular carcinoma
56
What are secondary causes of constipation?
1. DM
2. MS
3. Dehydration
4. Hypothyroid
5. Drugs (opioids)
57
what classifies as constipation?
less than 3 stools a week
58
What labs should you get on someone with constipation
1. CBC
2. CMP
3. TSH
59
By how much should someone increase their fiber intake if constipated
20-25 grams a day
60
What are examples f bulk forming laxatives?
1. metamucil
2. fibercon
3. citrucel
4. benefiber
61
what is an example of osmotic laxative?
polyethylene glycol (PEG), This can be used in someone not responding to bulk formin laxatives
62
Inflammatory diarrhea ( bloody diarrhea with fever) indicates what?
This mean it is an invasive organism or IBS
63
What are some infectious causes of bloody diarrhea?
1. Salamonella
2. Shigella
3. entero-toxic ecoli
4. campylobacter
5. C. diff
64
How long does giardia incubate for?
1-3 weeks
65
What kind of stool does giardia produce?
bulky foul smelling, will also have bloating and flatulence
66
Tx for giardia?
tinidazole
67
Afebrile abdominal pain with bloody diarrhea is what?
Shiga toxin-producing Escherichia coli
68
If there is a breakout of diarrhea in a day care setting what is the most likely virus?
rotavirus
69
Diarrhea from cruise ship?
norovirus
70
a 67-year-old man with a long history of constipation presents with steady left lower quadrant pain. Physical exam reveals low-grade fever, midabdominal distention, and lower left quadrant tenderness. Stool guaiac is negative. An absolute neutrophilic leukocytosis and a shift to the left are noted on the CBC.
What is most likely diagnoses?
diverticulitis
71
a 63-year-old male who is being evaluated in the emergency department for an episode of painless bright red blood per rectum for two hours.
What is this likely Dx?
diverticulosis
72
What is the most common location for diverticulitis?
sigmoid colon
73
How do you diagnose diverticulitis?
abdominal/pelvic CT scan
74
what will an abdominal/pelvic CT of someone with diverticulosis show?
Fat stranding and bowel wall thickening
75
What is the most common cause of massive lower GI bleeding?
Diverticulitis
76
antibiotic Tx for diverticulitis?
Ciprofloxacin or Augmentin/ + Metronidazole (Flagyl)
77
OTC treatment for diverticulitis?
increase fiber in diet and take bulk forming laxative such as metamucil
78
a 54-year-old female with odynophagia (painful swallowing), dysphagia and retrosternal chest pain.
What is the likely Dx?
esophagitis
79
What is the hallmark sign for infective esophagitis?
odynophagia (pain with swallowing food or liquids)
80
A pt with asthma presents to the clinic with symptoms of GERD that is non-responsive to tx. What is on you DDX?
eosinophilic esophagitis
81
How do you Dx eosinophilic esophagitis?
biopsy
82
What will a barium swallow of someone with eosinophilic esophagitis show?
a ribbed esophagus and numerous corrugated rings
83
What are some primary agents that causes infectious esophagitis?
1. HSV
2. Candida
3. CMV
84
A patient comes to the office complaining of odynophagia and chest pain. Upon exam they show to have linear yellow-whit plaques in their mouth. What do they have and what is treatment?
1. Candida albicans
| 2. fluconazole 100mg po daily
85
A pt who you suspect to HSV causing their painful swallowing is in the office. What imaging do you want to get and what will it show.
1. EGD
| 2. shallow punched out lesions
86
Tx for HSV esophagitis?
acyclovir
87
You want imaging on someone you suspect to have CMV esophagitis. What are you going to order and what do you suspect itll show?
1. EGD
| 2. Large solitary ulcer or erosions
88
Tx for CMV esophagitis?
ganciclovir
89
tx for oral candida?
fluconazole 100mg
90
tx for corrosive esophagitis?
Steroids
91
tx for eosinophilic esophagitis?
inhaler with oral steroid
92
What are the 3 causes of gastritis?
1. H. Pylori
2. NSAIDs
3. autoimmune
93
Where would gastritis from H. Pylori be primarily located
antrum and body of stomach
94
How do you diagnose H. Pylori
urea breath test or fecal antigen
95
What is included in the quadruple therapy for H. Pylori
1. tetracycline
2. metronidazole
3. PPI
4. bismuth
96
What anemia can be associated with gastritis?
pernicious anemia
97
If someone you suspected had gastritis symptoms and you trialed a PPI for 6-8 weeks with no response what would you think about do next to diagnose the issue?
upper GI endoscopy with biopsy and ultrasound
98
At hemoglobin level do you transfuse blood if they are a high risk patient (elderly, CAD)
HGB <9
99
What HGB level do you transfuse a low risk patient
HgB< 7
100
What do you tx GI bleeds with until source of bleed is discovered.
IV PPI
101
Mom brings in child that complains of itchy asshole especially at night. What test do you want to do to confirm your Dx?
Scotch tape test done early in the morning
102
Tx for pinworms
mebendazole
103
What kind of anemia is associated with a tapeworm
vitamin B12
104
what is the most common intestinal helminth (bug?) worldwide?
the roundworm
105
Causes of heart burn
1. Acid reflux
2. Food intolerance
3. hiatal hernia
4. esophagitis
5. Gastritis
6. PUD
106
Gold standard for Dx heartburn
endoscopy with biopsy
107
other than endoscopy with biopsy what other methods are there for Dx heartburn?
1. 24 hour ph monitoring
2. manometry
3. barium esophagography
108
treatment for zollinger-ellison syndrome
PPI therapy then surgical removal of tumor
109
When would you expect an umbilical hernia to present?
This are usually congenital and present at birth
110
When should you consider surgery for an umbilical hernia?
If it does not go away after 2 years of life
111
Which type of hernia goes through the inguinal canal and which goes through the hesselbach triangle?
indirect goes through canal (an I for an I)
direct well hesselbach triangle
112
Which type of IBD is isolated to the colon?
Ulcerative colitis
113
does ulcerative colitis have skip lesions or is it continuous?
it is continuous
114
What are the signs and symptoms of ulcerative colitis?
1. Hematochezia, pus-filled diarrhea, tenesmus
115
A lead pipe appearance with a barium enema means what? A cobblestone appearance with a barium enema means what?
1. Lead pipe equal ulcerative colitis
| 2. Cobblestone crohns
116
True or False: Crohns affects everything from mouth to anus?
true
117
Does crohns disease produce bloody diarrhea?
nope
118
What symptom in the mouth can point to crohns disease
aphthous ulcers
119
curative tx for ulcerative colitis?
Colectomy
120
Pharmacotherapy for ulcerative colitis and crohns?
Prednisone and mesalamine
121
A 24-year-old man with ulcerative colitis receives Lomotil for excessive diarrhea and develops fever, abdominal pain and tenderness, and a massively dilated colon on abdominal x-ray. This patient is presenting with what?
Toxic megacolon
122
Tx for toxic megacolon
decompression of the colon
123
What is the first sign of jaundice?
scleral icterus
124
Fifty-year-old with a history of coronary artery disease experiencing recurrent cramping with postprandial abdominal pain. This describes a pt suffering from what?
ischemic bowel disease
125
what is the most common artery affected by ischemic bowel disease
superior mesenteric artery
126
what is the gold standard imaging for ischemic bowel disease?
Mesenteric angiography
127
tx for ischemic bowel disease?
1. Supportive: Bowel rest, fluids, antibiotics
2. Laparotomy with bowel resection for bowel infarction
3. Revascularization is the gold standard
128
Dark urine in the setting of jaundice indicates what?
an Increased amount of direct bilirubin
129
What can cause someone to be jaundice?
1. Hemolytic (prehepatic)
2. obstructive (posthepatic)
3. hepatocellular ( intrahepatic)
130
what type of bilirubin is increased in a patient with jaundice due to hemolysis?
indirect and unconjugated
131
Obstructive causes like gall stones and pancreatic cancer causes an increase in what kind of bilirubin?
conjugated and direct bilirubin
132
Someone who says they are having poops come out white have what issue.
Those are called alcoholic stool and have a biliary obstruction
Emergency medicine EOR
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