| oral/fecal transmission
contact with infected blood, semen or other fluids
IV drug use; transfusion or organ transplant prior to 1992 | Hepatitis Risk Factors |
| self-limited
transmitted fecal-oral
incubation for 15-50 days
self-limited, rarely causes complications
immunization is available
45% of U.S. popu. has antibodies | Tell me about Hepatitis A |
| Anti-HAV IgM (acute) anti-HAV IgG (resolving) | Labs for Hepatitis A |
| Transmission: Percutaneous;
Infected blood and body fluids
sexual incubation 25-160 days
Course: Chronic liver disease 1-5% of adults; 80-90% of children! Mortality 0.3-1.5% | Tell me about Hepatitis B |
| HBsAg (confirms)
Anti HBs IgM (acute)
Anti HBs > 6 months = chronic | Hepatitis B labs |
| Transmission: Percutaneous, IV Drug Users (50%)Transfusions (4%)
Incubation: 42-49 days
often co-infected with HIV
No vaccine available
Course: Chronic active hepatitis (70-90%), 20% develop chronic liver disease: Common cause of liver failure and cancer-- number one reason for liver transplant | Tell me about Hepatitis C |
| Anti-HCV appears in 6-37 weeks | Hepatitis C labs |
| USPSTF Screening recommendations for Adults 50-75 yrs. | High-sensitivity fecal occult blood testing annually;
Sigmoidoscopy every 5 years with FOBT every 3 years;
Screening colonoscopy q 10 years |
| USPSTF Screening for adults age 76-85 years | screening benefit not seen for 7 years; risk associated with colonoscopy higher then benefit of gain in life years; individual decision making for first time screening |
| USPSTF Screening for adults then 85 | Do not screen: Harm outweighs benefit |
| What symptoms of the GI tract should we ask about? | Abdominal pain, n/v, diarrhea, constipation, heartburn, excessive gas or flatus, needing to belch or pass gas by the rectum; pt. states they feel bloated, abdominal fullness, early satiety, anorexia (lack of appetite), change of bowel habits |
| What questions about bowel movements should we ask about? | Frequency of bowel movements, consistency (diarrhea vs. constipation), pain, (bloody, black, tarry stool (melena)), color of stools(white or gray stools can indicate liver or gallbladder disease), signs of jaundice or icteric sclerae |
| What prior medical problems should we ask about concerning problems of the Abdomen? | prior medical problems r/t abdomen (hepatitis, cirrhosis, gallbladder problems, pancreatitis); prior abdominal surgeries; foreign travel and occupational hazards, use of tobacco, alcohol, illegal drugs, medication history, hereditary d/o affecting abdomen in family's history |
| What are some abdominal pain differentials? | gerd; pud, gastric cancer, biliary colic, pancreatitis, pancreatic cancer, cholecystitis, appendicitis, diverticulitis, bowel obstruction |
| What is visceral pain? | results when hollow abdominal organs such as the intestine or biliary tree contract, distend, or stretch; results when solid organs such as the liver capsule is stretched; difficult to localize, palpable at the midline levels; AN EXAMPLE WOULD BE LIVER DISTENTION AGAINST CAPSULE IN ALCOHOLIC HEPATITIS |
| What is parietal pain? | originates from inflammation in the parietal peritoneum; (steady, aching pain, more severe than visceral pain, aggravated by movement or coughting; patients prefer to lay still) EXAMPLE: EARLY ACUTE APPENDICITIS RESULTING IN VISCERAL PERI-UMBILICAL PAIN, PERITONITIS. |
| What is referred pain? | pain originates in organ that is innervated at approximately the same spinal lefels, superficial or deep but usually localized; EXAMPLE: DUODENAL OR PANCREATIC PAIN REFERRED TO BACK; PAIN FROM BILIARY TREE REFERRED TO THE RIGHT SHOULDER. |
| What are the types of diarrhea? | Acute < 30 days; Drug Induced; Chronic > 30 days |
| What is acute diarrhea? | Secretory infection(non-inflammatory); inflammatory infection |
| What are examples of chronic diarrhea? | IBS, UC, Crohn, Fecal impaction, Lactose intolerance, Laxative abuse |
| What are some causes of constipation? | Habits: diet, time/setting; IBD; Mechanical obstruction (cancer, fecal impaction); drugs; neurologic, metabolic |
| What is Melena? | black tarry stool = blood loss usually from upper-GI such as esophagus, stomach, or duodenum |
| What are some differentials for upper GI (bleed). | PUD; SMALL BOWEL AVM; MALLORY-WEISS; GASTRITIS; VARICES |
| What is hematochezia? | Frank red blood |
| Lower GI bleed comes from where? | colon, rectum, less frequently from jejunum or ileum; also large upper GI bleed can cause and if rapid transit |
| What are some differentials for lower GI bleed? | hemorrhoids, diverticulosis, inflammatory bowel disease, colorectal/anal cancer, colon polyps, infectious colitis, NSAID colopathy |
| What is Hematemesis? | vomiting blood |
| What are some differentials for hematemesis? | mallory-Weiss tear (tear in the esophageal mucosa caused by prolonged/vigorous retching; peptic ulcer disease, gastritis, esophageal/gastric varices; Gerd/esophagitis |
| What is dysphagia? | difficulty with the act of swallowing. (also see power point) |
| What is heartburn? | a burning sensation in the epigastric area radiating into the throat; often associated with regurgitation; cough |
| What is regurgitation? | the reflux of food and stomach acid back into the mouth; brine-like taste |
| What is the health promotion and disease prevention of heartburn? | Identify GERD and treat b/c untreated GERD leads to Barrett's esophagus=esophageal dysplasia |
| What are some diagnostics for heartburn? | PPI trial; EGD; barium swallow, ambulatory ph monitoring |
| What is n/v? | retching (spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed) FOR N/V WE NEED TO DIFFERENTIATE WHETHER IT IS ACUTE OR CHRONIC OR GI OR NON-GI |
| What are things we should ask about in n/v? | amount of vomit; type of vomit (food, green - or - yellow- colored bile, mucus, blood, coffee ground emesis (often old blood) |
| What is hematemesis? | blood or coffee ground emesis |
| What are some common acute genitourinary problems? | UTI - cystitis, bladder infection, pyelonephritis; RENAL CALCULI |
| What are some common chronic genitourinary problems? | chronic uti; benign prostatic hyperplasia, bladder cancer, prostate cancer urinary incontinence |
| For history taking of problems of the abdomen: urinary tract | SEE POWER POINT |
| What is dysuria? | difficult urination and /or painful urination |
| What are some differentials for dysuria? | cystitis, urethritis, uti, bladder stones, acute prostatis |
| Urinary urgency? | intense, immediate urge to void |
| Urinary frequency? | abnormally frequent voiding |
| What is nocturia | urinary frequency at night (low-volume- habit or insomnia) (high volume - think pathologic such as CHF or kidney disease) |
| What is polyuria? | increase in 24 hour urine volume > 3liters, think poorly controlled DM, diabetes insipidus, psychogenic polydipsia |
| What is stress incontinence? | small amount of urine leakage caused by coughing, laughing, sneezing, unrelated to conscious urge to urinate, related to weak urethral sphincter overcome by intra-abdominal pressure. This can happen in post-childbirth, menopausal, post prostate surgery PE: atrophic vaginitis, absence of bladder distension |
| What is urge incontinence? | moderate amount; preceded by urge to void; r/t detrusor contractions stronger than normal and overcome urethral resistance. |
| What is urge incontinence caused by? | UTI; bladder habits (frequent voiding low volumes = deconditioning), s/p CVA, dementia, rain tumor, spinal cord lesions; PE = small bladder, tenderness if UTI, CNS deficits, fecal impaction |
| What is overflow incontinence? | continuous dripping or dribbling |
| What is overflow incontinence caused by? | bladder outlet obstruction, detrusor muscle weakness, impaired bladder sensation = urinary retention, detrusor contractions not able too overcome urethral resistance PE = enlarged bladder, prostate hypertrophy, neurological-sensory motor deficits (diminished perineal sensation/reflexes). |
| What is hematuria? | Gross-seen by naked eye; microscopic, differentiate - urine or menstrual |
| What are some differentials for hematuria? | uti/pyelonephritis, bladder cancer, kidney stones, rhabdomyolysis (extreme/CrossFit workouts) |
| What is flank pain/ureteral colic? | flank is at or below posterior CVA; ureteral is posterior CVA pain that radiates to lower abdomen/groin |
| What are associated symptoms for flank pain/ureteral colic? | fever/chills, dysuria, frequency, fatigue suggest acute pyelonephritis; nausea without fever/chills suggest kidney stone |
| What are diagnostics for flank pain/ureteral colic? | UA, C/S, CBC, BMP, non-contrast CT abdomen for stones (80% calcium stones); hydro-nephrosis; stone analysis |
