Week7 6671/6611

Question 1

SBO- small bowel obstruction

Causes (common)

Answer 1

Adhesions
Hernias
Inflammatory diseases
Tumors

Question 2

SBO - small bowel obstruction

S/S

Answer 2

Cramping and abdominal pain (5-15 min waves; centered on navel or between navel and rib cage) 
Nausea and vomiting 
No gas passing through the rectum 
Abdominal bloating
Rapid pulse and rapid breathing 
Upper epigastric distention 
Constipation 
Lack of appetite

Question 3

LBO- large bowel obstruction

Common causes

Answer 3

Colorectal cancer
Volvolus
Diverticular disease

Question 4

In general obstruction of small intestine presents with ____, as ____ tends to be more large bowel obstruction.

Answer 4

Colicky abdominal pain and vomiting (SBO)

Distention and absolute constipation tend to be more common in large bowel obstruction

Question 5

LBO- large bowel obstruction

S/S

Answer 5

Lower abdominal bloating/distention 
Lower abdominal cramping and pain 
Constipation
Diarrhea 
Possible rectal bleeding

Question 6

80% of bowel obstruction are ___

Answer 6

Large intestines (LBO)

In developed countries- usually from adhesions.

Question 7

Volvolus

Answer 7

Twisting of bowel around itself
(LBO)

Most common >65 y/o w/ hx of chronic constipation

Question 8

Red flags for immediate medical referral

Answer 8

Intense and/or constant abdominal pain

Vomiting

Bloating

Blood in the stool

Question 9

GI system checklist

Answer 9

Swallowing difficulties
Indigestion/heartburn
Food intolerance
Nausea/Vomiting

Bowel dysfunction: 
Color of stool
Shape, caliber of stool
Diarrhea 
Difficulty initiating 
Incontinence

Question 10

Causes of dysphagia

Answer 10

Muscle incoordination:
Myasthenia gravis 
MS 
Amytrophic lateral sclerosis 
Parkinson’s 

Mechanical obstruction: 
Tumors
Thyroid goiter 
Osteophytes of c-spine
Aortic aneurysm

Question 11

Clinical manifestations of dysphagia- motor cause

Answer 11

Onset: gradual
Progression: slow
Equal difficulty w/ soft foods vs liquids
Worse swallowing cold substances
Bolus passage: repeated swallowing; valsalva maneuver, throwing back head and shoulders

Question 12

Clinical manifestations of dysphagia- Mechanical cause

Answer 12

Onset: faster
Progression: faster
More difficulty swallowing solids than liquids
Swallowing difficulty not affected by temperature
Bolus passage: can be accompanied by regurgitation

Question 13

Questions to ask about dyspepsia (indigestion/heartburn)

Answer 13

How long have you had symptoms?
Do you know what is causing?
Constant or intermittent?
How are you treating the symptoms?

Associated symptoms:
Fatigue
Weakness
SOB

Question 14

Common food intolerances

Answer 14

Cheese
Chocolate 
Citrus 
Nuts 
Red wine 

Can be warning sign for underlying pathology - ie gallbladder

Question 15

Melena (GI bleeding- dark)

Questions to ask

Answer 15

How long have you been having black, tarry stools?
Have you felt lightheaded?
Have you had any nausea, vomiting, diarrhea, fatigue, abdominal or back pain, or sweats associated with these stools?

Question 16

Obstructive jaundice

Questions to ask

Answer 16

How long have you noticed the light, pale-colored stools?
Have you noticed an atypical color (ie dark) of urine?
Have you noticed any associated symptoms such as fatigue, fever, chills, unexplained weight changes or nausea?

Question 17

Hematochezia (red blood stools) questions to ask

Answer 17

How long have you noticed bright red blood in your stool?
Is the red blood mixed within the stools (red streaks) or not?
Are there any associated symptoms, such as difficulty in initiating bowel movements or feeling of lightheadedness or fatigue?

Question 18

“Have you noticed any unusual shape of your stool recently, such as pencil-like in diameter, flat and ribbon-like?”

Question is asking about?

Answer 18

Colon carcinoma

Question 19

Potential causes of constipation

Answer 19

Impaired mobility 
Inadequate dietary fiber 
Inactivity 
Diverticulitis 
Hypothyroidism 
Hypercalcemia 
Scleroderma 
Neurologic dysfunction 
MS
SCI 
Psychosocial dysfunction 
Depression/Anxiety 
Situational stress

Question 20

Potential causes- diarrhea

Answer 20

Infectious agents 
Laxative abuse 
Colon cancer 
Irritable bowel syndrome 
Crohn’s 
Ulcerative colitis 
Diabetic enteropathy

Question 21

Diarrhea questions to ask

Answer 21

How many episodes each day?
How long gave you gas diarrhea?
Do you ever have periods of diarrhea alternating with periods of constipation?
Is diarrhea worse at certain times of day?
Do family members or companions have similar symptoms?
Do you have any associated symptoms such as fever, chills, nausea, vomiting, confusion or abdominal pain or distention?

Question 22

S/S of dehydration

Answer 22

Thirst and dry mouth 
Postural hypotension 
Rapid breathing 
Rapid pulse (>100 bpm) 
Confusion, irritability, lethargy 
HA

Question 23

Hematuria

And questions to ask

Answer 23

Blood in urine

How long have you noticed red urine?
Do you have a hx of bleeding problems?
What medications are you currently taking?
Do you currently have, or have you recently recovered from an upper respiratory infection or sore throat?

Question 24

ED can be associated with

Answer 24

SCI
Herniated disk 
Post surgical complications: radical prostate, bladder, colon procedures 
DM
Medication side effects 
Psychogenic disorders

Question 25

Causes of bowel obstruction

Answer 25

Mechanical: Adhesions Hernias Tumors ``` Other: Diverticulitis Foreign bodies Intussusception Fecal impaction ``` Also consider: Ogilvie syndrome; Post-op ileus

Question 26

About __% of partial bowel obstructions resolve without operative tx About __% of complete bowel obstructions require surgery

Answer 26

85% | 85%

Question 27

Suspicion of bowel obstruction requires?

Answer 27

Hospitalization

Question 28

Bowel resection

Answer 28

AKA partial colectomy Can be open or laparoscopic Obstruction, Cancer, Crohn’s, diverticulitis, severe bleeding Sometimes colostomy needed

Question 29

Colostomy

Answer 29

Surgical procedure bringing portion of the large intestine through the abdominal wall to allow passage of bowel material out of the body as an alternative to the anus

Question 30

Reasons for colostomy

Answer 30

Treat various large intestine disorder (cancer, obstruction, IBS, ruptured diverticulum, ischemia) Can be temp to divert stool from injured/diseased section of large intestine Can be permanent when distal bowel removed or blocked or inoperable (ie colorectal ca)

Question 31

3 types of colostomy

Answer 31

1. End colostomy- usually permanent 2. Double barrel colostomy- usually temp 3. Loop colostomy- usually temp

Question 32

Stoma

Answer 32

External opening of the colostomy Made by bringing end of intestine through an opening in abdomen and attaching it to the skin Serves as connection for removable external collection pouch (ostomy appliance)

Question 33

Colostomy post-op care

Answer 33

NG tube w/ low to intermittent suction until bowel activity returns Stoma monitored w/in 72 hrs passage of stool begins Diet (advanced as stoma becomes active) Psychological consult ERAS D/C home 2-4 days depending on pain and GI activity; Possible return in 3-6 mo for colostomy “take down”

Question 34

PT implications- post-colostomy

Answer 34

Activity restrictions: No driving, heavy lifting 2-3 weeks Avoid extreme physical exercise and sports for 3 mo Eventually no activity restrictions, except maybe contact sports Swimming is fine and encouraged.

Question 35

BMI

Answer 35

< 18.5 underweight 18.5-24.9 normal weight 25-29.9 overweight 30-34.9 obese-1 35-39.9 obese-2 40 and < morbidly obese

Question 36

Waist circumference | Obesity

Answer 36

Men > 40” Women > 35” Increased risk of heart disease and DM2

Question 37

Bariatric

Answer 37

Branch of medicine that deals with causes, prevention and tx of obesity

Question 38

Clinical manifestations of obesity: Increased risk of...

Answer 38

``` CV disease DM Stroke Arthritis Gallbladder disease Respiratory conditions Cancers ```

Question 39

Metabolic syndrome

Answer 39

Group of conditions that lead to development of CV disease and DM2 Primary risk factors: Abdominal (central obesity) Insulin resistance

Question 40

Metabolic syndrome - Dx

Answer 40

Dx with 3/5 conditions met 1. Waist circumference M > 40” F>35” 2. Fasting glucose 100 mg/dL or use of meds for hyperglycemia 3. Triglycerides > or = 150 mg/dL 4. BP > or = 130/85 or use of HTN meds 5. HDL M<40 mg/dL F<50 mg/dL

Question 41

Wight distribution

Answer 41

Apple: Apple pannus- inferior abdominal drift of adipose Apple ascites- large abdomen, don’t tolerate lying flat Pear: (Mostly in F) Pear ABD- more weight hips/butt downward, tends to have knee valgus Pear ADD- tends to have knee varus Gluteal shelf- large gluteal mass of adipose

Question 42

Mobilizing obese

Answer 42

Transfer sheets, overhead grab bar or trapeze, bariatric gait belts, other bariatric equipment Spend more time planning than doing Include pt in decision making Number of people needed - consider 2-3 at most

Question 43

Normal/Standard medical equipment is usually rated for about ____. Bariatric equipment for ___.

Answer 43

250-300 lb max Bariatric equipment rates for over 300 lbs

Question 44

Mobilizing/Positioning - | Apple ascites obese

Answer 44

Little tolerance for supine or prone Positioning Supine -> Sit: flat spin with a sheet

Question 45

Mobilizing/Positioning - | Apple pannus obese

Answer 45

Variability with supine tolerance Supine -> Sit: Flat spine w/ sheet or prone flat spin w/ UE push up to stand

Question 46

Mobilizing/Positioning - | Pear obese

Answer 46

Supine -> Sit: via long sitting to raise head of bed and use sheet to assist to EOB

Question 47

Gait belt grips - obese

Answer 47

Thumb grip: Face pt, cross arms, hand under belt from top palm out, bring 2 fingers to thumb, Control slack w wrist flexion, radial deviation, elbow flexion Twist grip: Pt side, hand down into belt palm to back, twist toward thumb, control slack w wrist flexion, radial deviation, elbow flexion

Question 48

Egress test | Sage to ambulate w/ bariatric pt

Answer 48

1. Ask pt to lift bottom off surface as if going to stand (1-2 inch clearance) then return to sitting 2. Ask pt to come all the way up to standing and bear weight on both LE 2x 3. Ask pt to perform 3 reps of March in place 4. Ask pt to take 1 step forward and then return to start position. Do this bilaterally.

Question 49

Bariatric- exercise rx | Goals

Answer 49

Pt centered- behavior modification (not always weight related) Weight loss 10% at 1-2 lbs a week Increase physical activity to reduce risk of obesity related disease- aim for up to 1 hour moderate intensity 5x/week

Question 50

Abdominal pain of MSK origin question clusters

Answer 50

cluster 1: 1. Does coughing, sneezing, or taking a deep breath make your pain feel worse? (Yes) 2. Do activities such as bending, sitting, twisting, lifting, or turning over in bed make you pain feel worse? (Yes) 3. Has there been a change in your bowel habit since the start of your symptoms? (No) Answering “yes” either to Q1 or Q2, and “no” to Q3 = moderate probability is MSK in origin Cluster 2: 1. Does eating certain foods make your pain feel worse? (No) 2. Has your weight changed since your symptoms started? (No) The probability increases to strong if both “no”

Question 51

Abdominal pain of MSK origin may present as

Answer 51

Sharp and focal, cramping and aching, or deep. In comparison, pain from visceral is often dull, aching, cramping, burning, gnawing, wave-like and poorly localized Both can present with nausea