EVERYTHING

Endocrine

Hyperglycemia:

• fastin: 106-110

• random: >200

• Body does not produce insulin, not effective

• Too much glucose

• Illness, infection, meds, stress, lifestyle

• T1&2DM

Pancreas:

• Endocrine

  • Beta (Langerhans) → insulin

    • Moves glucose → cell

    • No insulin = ^ BG, cells starve → breakdown of fat, protein & ^ production of glucose via liver

  • Alpha → glucagon: ^ BG

    • Stimulates liver to produce glucose

      • Glycogenolysis: glycogen → glucose

      • Gluconeogenesis: noncarbs

      • Lipolysis:

        • Ketones & DKA

      • Proteolysis

• Exocrine:

  • Amylase & Lipase

Patho:

• cells have low energy → liver ^ BG → glyco/gluconeogensis → ^ stress hormones (corticol, catecholamines, glucagon) → fat + protein break down → ^ BG → kidneys → glucose PULLS water & E+ to urine → dehydration & E+ loss

  • Osmotic Diuresis:

    • Leads to polyuria, dehydration, v Na, K, volume, BP, & ^ HR

S/s:

• 3 Ps: Polyuria, dipsia, phagia

• Dry mouth & membranes, blurry vision, weak

• Tired, headahce, v weight, poor wound healing

Severe:

• Hypotension, Tachycardia

• Dehydration → Confusion & Lethary & AMS → coma

DKA: Insulin deficiency → Lipolysis → Ketones → Acidosis → v Bicarb

• Fruity breath & Kussmaul

  • Body trying to compensate acidosis by removing CO2

• N/V, Abd pain

• Dehydrated & AMS

• Common with T1DM

HHS: High BG but still not insulin deficient, just not enough insulin to use

• Extreme ^ BG, severe dehydration, ^ osmolality

• Hypotension, AMS, X Ketones

• T/x:

  • IV fluids, Insulin, E+ monitoring

R/x:

• Modifiable:

  • Weight, diet, lifestyle

  • SMOKING, stress, sleep

    • Sleep:

      • Insomnia, OSA may lead to ^ BG as poor sleep causes

        • ^ BG levels & insulin resistance

  • nonadherence to meds

• Nonmodifiable:
      Family h/x, genes, age

• Illness-related:

  • Infection, Surgery, Physical/Emotional stress

• Medication-related:

  • Glucocorticoids

  • Phenytoin

  • Estrogens

  • Some diuretics (thiazide & loop)

    • Hypokalemia → Lower insulin excretion by pancreas → ^ BG levels

• T/x-related:

  • TPN, Dextrovse IV

Chronic Hyperglycemia:

• CV: dmg to vessels

  • CAD, MI, Atherosclerosis, PVD

  • HTN

• Neuro:

  • Neuropathy

  • Numb/Tingling, Neuropathic pain

  • STROKE

  • Poor vision

• Renal:

  • AKI → CKD

• Skin:

  • Poor wound healing & infection ^

D/x:

• BG testing

  • Fingerstick is helpful for confused/aggresive patients to help quickly i/x problem

  • Venous is gold standard for accurate tests

  • Fasting is more accurate > Random

  • Postprandial = BG AFTER eating

• HA1C: reflects average BG levels over 2-3 months

  • 5% → 100

  • 6% → 135

  • 7% → 170

  • 8% → 205

• Imaging may help rule out tumor or endocrine disorder

T/x:

Lifestyle:

• Lower portions, lower simple carbs

• Exercise, manage stress & sleep, X smoking

  • Exercise:

    • DO NOT when ketones as it can ^ BG & hormone levels

Meds:

• Oral hypoglycemis & Noninsulin injectables:

  • Metformin: v glucose production & ^ insulin sensitivity

  • Sulfonylureas (Glyburide, Glipizide, Glimepiride): ^ insulin secretion

  • Others:

    • Thiazolidenodions, SGLT2 (^ glucose urination) X, DPP-4 X

• Insulin:

  • Scheduled insulin > sliding scale becauase it is more proactive

• Med dosage

Severe ^ BG:

• IV isotonic fluids → treat dehydration

• IV insulin

• E+ Replacement

  • Cardiac monitoring

Glucose Monitoring Supplies:

• Protect strips from moisture, extreme heat

• Do NOT reuse lancers or share them

MAKE THEM WEAR a med identification bracelet

Sickday:

• Continue meds, check BG, check urine/ketones, hydrate

• Notify provider on a/e

• Drink 4-6 oz q30 mins → eat 50g carb q4hr

• Check temp 2x/day

• Hypoglycemia → 15-15 rule

Hypoglycemia:

• <70

• May lead to seizures, v LOC, coma, dysrhythmias

Levels:

1. 54-70

2. <54

3. Based on the condition

Hypoglycemia Unawareness: pt does not have warning s/s like shaky, hungry, sweating

• may lead to more serious s/s first

• Pt may require:

  • Higher glucose targets, monitoring, education, and easier access to glucagon

• May also cause fear, anxiety and v QOL due to possible events

Nocturnal Hypoglycemia:

• Night sweats, nightmares, poor sleep, morning headaches, tired

• Continue BG monitoring

Neuroglycopenia: when brain does not receive glucose

• Confusion, Irritable, Blurry vision, seizures

Patho:

• v BG → SNS activate → epi & norepi release → pancreas releases glucagon → liver → glycogenesis → not enough → sweating, shaky, hungry → neurologic s/s → seizure, coma → death

Causes:

• Medication-related:

  • Too much/early insulin

• Nutrition:

  • missing, not eating

  • Anorexia, fasting

• Alcohol-related:

  • Prevents liver from releasing glucose

  • More prominent if taken w/out food, exercising alot, or with v BG meds

• Trauma, surgery, Pancreatitis, Liver disease, CKD

Remember that BB can mask hypoglycemia warning signs:

• Tachycardia, Palpitations, Tremors, Sweating

S/s:

• Adrenergic:

  • Shaki, Tremor, Sweat, Chills

  • Cold & clammy needs candy ahh phrase

  • Hunger, A, Nervous, Tachy, palpitations

• Neuroglycopenic:

  • Confusion, headache, dizzy

  • blurry, weak, sleepy

  • Seizure, X LOC, coma

  • v weight

    • >5 lbs

D/x:

• Continuous GM:

  • Real-time

  • Intermittent

  • May be less accurate with temp, o2, and tylenol taken

15-15 rule:

• only when pt is awake, alert & able to swallow

• Check BG → 15g → wait 15 mins → if low another 15g → repeat

• Fast acting carbs:

  • 3-4 glucose tabs

  • 1 gel

  • 4oz of juice/soda

  • 1 tb of sugar/honey/syrup

  • 6-8 candies

  • 8oz of milk

Glucagon: stimulates liver to release glucose

• Turn pt to side

IV dextrose:

T1DM: i.s. destroys beta cells → X insulin production

Patho:

• Pancrea autoantibodies ATTACk B cells → lower function → X insulin → glucose is trapped in blood → body breaks down fat & muscle → ketones → DKA

Stages:

1. 2+ autoantibodies present; BG expected

2. Abnormal glucose regulation, poor glucose tolerance

3. Hyperglycemia & s/s present

Causes:

• Genes, family h/x

• Possible viral trigger

• Ages 4-6 & 10-14

S/s:

• 3 Ps

• Weight loss, dehydration, fatigue, weak, blurry vision, dry skin, infection

• May leads to DKA

  • >250 BG, ketones, urine glucose & ketones, metabolic acidosis

Long-term:

• Macro:

  • CAD, MI, Stroke, PVD

• Micro:

  • Retinopathy, Nephropathy, Neuropathy

  • Ulcers

  • Dermopathy:

    • Scaly patches in lower legs

D/x:

• HgA1C

• Urinalysis:

  • Reveals Glucose, Acetone, Ketones

• C-peptide: reflect insulin production

T/x:

• Lifelong insulin, monitoring, nutrition management, excersie

• Hypoglycemia prevetnion

• Ketone monitoring

INSULIN: 100 units per mL

• Rapid-acting: Lispro, aspart, glulisine

  • O: 15-30

  • P: 30-3hrs

  • D:3-5 hrs

• Short-acting: regular

  • O: 30-60

  • P: 2-4hr

  • D:4-12

• NPH

  • O: 1-2hr

  • P:4-12

  • D:14-24

• Long-acting: Glargine, Detemir

  • O: 2-4hr

  • D:24hr

• Glargine U-300

  • D:24-42hr

Storage:

• Unopened → fridge

• Opened → fridge for 1 month

• Keep from:

  • Sunlight, heat, freezing, extreme temps

T2DM: Insulin resistance, progressive B-cell dysfunction, & ^ liver glucose production

• HHS more common

• C-peptide normal

Patho:

• Body becomes resistant to insulin → glucose cannot enter → pancrease ^ insulin production → B cells become overworked → v insulin production over time → glucose stays in blood → hyperglycemia

• Losing more than 3% of TBW can reduce DM r/x from PreDM

R/x:

• modifiable:

  • Obese (most prominent), sedentary, poor sleep, stress

  • SMOKING, poor activity

• Nonmodi:

  • Age, family h/x, genes

  • Gestational diabetes h/x

s/s:

• Same as Hyperglycemia

• Acanthosis Nigricans: dark skin w/raised patched

  • On neck, armpits

  • Due to insulin resistance

D/x:

• Fasting BG: >126

• Oral glucose tolerance test: >200

• Random BG: >200

• HbA1C: >6.5

  • Targets:

    • <7%

    • <8%: fair but needs more work

Nutrition:

• Mediterannean style eating

• >3% weight loss

Metformin:

• May CAUSE lactic acidosis

  • A/x muscle cramps, malaise, severe weakness

Canagliflozin: SGLT2 (glucose → urine)

• May lead to AKI (lower urine output, burning), severe dehydration & hypotension

• Take w/first meal of day

Bariatric Surgery:

• Helps lower weight significanlty & improve sensitivity

Metabolic Syndrome: cluster of interconnected metabolic & cv problems

• Components:

  • Central obesity, insulin resistance, hyperglycemia, HTN, ^ Tgcerides, v HDL, Hyperlipidemia, inflammation

  • Low grade inflammation may leads to → cancers, dementia

• All of these lead to:

  • T2DM, CVD, stroke, KD, liver disease

Patho:

• Too much visceral fat → adipose tissue releases inflammatory chems → adipokines → worsens insulin signlaing → resistance to insulin → ^ BG → pancreas ^ insulin production

Central obesity: fat around abdomen & intestines

• >35 females; >40 males

• Leads to insulin resistance

Steatoic Liver disease: too much fat in liver → cirrhosis

DEMENTIA: from Metabolic syndrome

S/s:

• Central obestive, ^ BG, HTN, Bad lipids

• BMI >30

• <50 HDL

R/x:

• PreDM, T2DM, HTN, Polycystic ovary syndrome, OSA, CKD, CVD

Treatment:

• Lock in

• No smoke or alcohol

• Meds

• CPAP → OSA

• Bariatric surgery

Antiobesity Meds:

• Orlistat: v digestion of fat

  • A/e:

    • oily stools

    • v V ADEK

Thyroid chain:

• TRH → TSH → T3 & T4

Hypothyroidism:

• Primary: High TSH & low T4; happens in thyroid

  • Hashimoto, low Iodine, thyroid surgery or radition therapy

• Secondary: Low TSH low T4; happens in pituitary

• Tertirary: Hypothalamush; no nothing

Causes:

• Hashimotos disease: i.s. attacks thyroid

• v Iodine: needed for T3&4 production

• Surgery

• Tumors in pituitary or radiation therapy

• Meds:

  • Amiodarone, lithium, -zumab, antithyroid meeds

R/x:

• Female, older, family h/x

S/s:

• Fatigue, Weak, ^ Weight

• Cold intolerance, puffy, edema

• v HR, HTN!, Prolonged QT

• Dry course thin skin

• Weak muscles

• Heavy/irregular menstruations

• Deep/hoarse voice, sleep apnea

Goiter

Myxedema → puffy face, nopitting edema

• May lead to coma ifuntreated

  • Causes:

    • Infection, cold, surgery, trauma, sedatives, HF, stopping meds/t/x

  • s/s:

    • Severe hypothermia, v BP, v HR, Hypoxia, facial swelling, confused, coma

Treat v TH when pregnant as it can cause fetal growth/neurologic defects

T/x:

• Levorthyroxine: replaces thyroid hormones

  • Give 1 hr before a meal or 3hrs after

  • Avoid:

    • Ca Fe Al Mg supplements

  • A/E:

    • Hyperthyroidism effects

    • Constipation

Hyperthyroidism:

Thyroidtoxicosis: bodys response to too much hormones

Causes:

• Too much thyroid

• thyroiditis

• Graves disease:

• Female & older age

• Pernicious anemia ^ r/x

S/s:

• Weight loss, weak

• Heat intolerance, tremors, restless

• Tachy, HTN,palpitations

T/x:

• Methimazole

  • May cause itching and hives & v CBC

Gas exchange

Asthma: Chronic inflammation → wheezing, breathless, chest tight, cough

• Caused by:

  • Exercise

  • Allergens

  • Viral

  • Irritants: smoke, chemicals, weather, perfume

  • Common in males before puberty; after is females

Patho:

• Inflammation + edema + excess mucus → bronchospasms → contracts & clogs

• MORE PRONOUNCED during EXPIRATIOn

• IgE → Allergens → binds to mast cell

  • Early Phase: mast cells release histamines, Leukotrienes, Pg → bronchoconstriction

  • Late Phase: eisonophils migrate to airway → ^ leukotrienes → sustained inflammation

• Issues breathing → hypoxemia → hyperventilaite → v CO2 → chronic → airway remodeling (thicker, hypertrophy) → more obstruction

Types: may have 1+ phenotype

• Allergic: childhood

  • Seen w/hay fever/eczema

• Nonallergic: adults

  • Corticosteroids help w/t/x

• Aspirin:

  • Aspirin/NSAIDs

• Excersive induced

Causes:

• Genes

• Environment

• OBESITY: ^ r/x

• Puberty

S/s:

• Wheeze, cough, chest tight, dyspnea

  • Cough: night/morning → mucous plug

• Use of accessory muscles

• Wheezing; absent = life threatening

• ^ HR, RR, ^ BP initially due to stress

Frequency:

• Intermittent:

  • Day: <2days/week

  • Night: <2/month

• Mild:

  • D:>2days/week

  • N: 3-4/month

• Moderate:

  • D:daily

  • >1/week

• Severe:

  • Throughout day

  • N:>7/week

D/x:

• Oximetry

• Peak flow meter: measures output during expiration

  • Challenge based

• Spirometry: a/x bronchodilator effectiveness

V/Q:

• V= ventilation

  • Air → alveoli

• Q= perfusion

  • B.f. in pulmonary capillaries

• Mismatch: hypoxemia

  • Dead space: volume of air that does not participate in lung exchange

T/x:

• SABA: albuterol

  • May lead to CNS stimulation → tremor, tachy/palpitations

• Ipratropium:

  • Onset of 30 mins

  • Nebulize = eye protection

Long-term:

• ICS: anti-inflammatory control

  • May cause oral thrush or dysphonia

    • Use spacer + mouth wash

Status Asthmaticus:

• Severe exacerbation w/ hypoxemia, hypercarbia, ^ 2ndary resp failure

Patho:

• More intense

• Mast cells → ^ inflammatory mediators & cytokines → destroys cillia → goblet cells & → thicker secretions → mucus plugging → asphyxia → lactic acidossis

  • May ventilate first → resp alkalosis → later → acidosis → req ventilation

• Stress & depression may cause nonadherence which ^ exacerbation r/x

R/x:

• H/x of prior intubations w/status asthmaticus

• Coronary artery disease → & r/x of A/E from meds

S/s:

• Extreme SOB, chest tight

• Accessory muscles used, drowsy & confused

• Cyanosis & Hypoxemia → ^ PaCO & v pH

• Silent chest/absent breath sounds → ER

• Restless, anxeity, agitated, & ^HR & BP initially

Pulsus Paradoxus: >10 mmHg drop systolic when breathing in

• Common in:

  • Severe Asthma/COPD

  • Cardiac Tamponade

D/x:

• PEFR & FEV v 50% = status asthmaticus

• PEFR <50% = emergency

T/x:

• SABA + short course systemic CS

• O2

• IV fluids

• Mg Sulfate to help relaxe smooth muscles

OSA: partial/complete collapse of upper airway when sleeping → pauses in breathing → poor sleep qualirt, snoriing, & daytime sleepiness

• v muscle tone in nasopharynx → ^ CO2

R/x:

• BMI >25/>30

• Large neck fat

• Nasal congestion or facial malformations

• HTN, CAD, HF, T2DM, asthma, COPD, GERD

S/s:

• Apneic episodes: breathing stopped >10 secs

• Increase risk of crashes due to poor sleeping

• May lead to:

  • Systemic HTN, arrythmia, MI, stroke, HF → pulmonary HTN

D/x:

• Overnight polysomnography (PSG): calculates number of episodes qHR of sleep

T/x:

• Nonpharm:

  • Weight loss, X alcohol, positional therapy (avoiding supine position)

  • MAD: puts jaw foward

• PAP:

  • CPAP: single continuous psi

  • BiPAP: ^ psi when inspirating; v psi when expirating

• Meds:

  • Tirzepatie: helps to reduce obesity & care for OSA

COPD:

Patho:

• persistent airway symtpoms → airflow limitation → t/x early on → not curable after → chronic bronchitis & emhpysema

Emphysema: permanent enlargement & destruction of alveoli → obstruction

• Proximal: smoking/coal miners

• Panacinar: Alpha A1-Antitrypsin deficiency

• Distal: spontaneous pneumothorax

Chronic Bronchitis: productive cough >3 months for 2 years → too much mucous & inflammation

• Too much smoking/poor air exposure → irritation → hypersecrertion & inflammation → mucous plugging

  • Inflammation causes macrophage to attack alveoli → & resp infection r/x

S/s:

• Dyspnea, chronic cough, sputum production

• Early sign: exertional dyspnea

• Barrel chest, tripod position, pursed-lip breathing, dystended neck veins

• Hoover’s sign: inward chest movement when breathing in

May lead to pnemonia & respiratory failure

• & Also thromboembolic disease & lung cancert

D/x:

• CAPTURE questionnaire & peak expiratory flow

• FEV1/FVC ratio

• C-XRAY to rule out pneumonia/HF

T/x:

• Take ur influenza & RSV caccine

• To maintain, take LAMA & LABA

• Smoking cessation

Pneumonia:

• Infection of lung parenchyma from bacteria, virus, or fungi

  • CAP: <48 hrs

    • Strep. pneumonia

  • HAP: >48 hrs

  • VAP: >48 hrs after ET

    • MSSA, MRSA, pseudomonas aeruginosa

• Lobar: entirle lobe

• Bronchopneumonia: patchy inflammation

• There is also aspiration & chemical pneumonia

Patho:

• Pathogen enters as droplet/airbone → chills in nasopharynx → travels to alveoli → infection

  • Inflammation occurs → exudate → neutrophils enter → secretions ^ → V/Q mismatch → lung abscess & empyema

R/x:

• Age >65, COPD, HF, Lung cancer

• COPD is the highest risk

Uncs:

• Fever may be absent, may be confused, fall ^ r/x, & having loss of appetite

• Make sure they vaccinated

S/s:

• Systematic: fever/chills, malaise, v appetite, myalgia

• Pulmonary: cough & sputum, dyspnea, pleuritic chest pain

• ^ HR, ^ RR, crackles, dullness, tactile fremitus

• May lead to:

  • Empyema, Lung abscess,ARDS, sepsis, resp failure

D/x:

• C-xray

• CT chest: to better detect

• Blood cultures: do it BEFORE giving Antibiotics

T/x:

• ABC, Fluids to thin secretions

CURB-65: a/x mortality r/x for CAP pts

• C: confusion

• U: Urea (BUN >19)

• R: RR >30

• B: <90/<60

• Age >65

If:

• 0-1: outpatient

• 2-3: admit

• >4: ICU

Pulmonary Edema: too much fluid in interstitial space & alveoli

• Cardiogenic → CHF/LVF/MI (ADHF most common driver)

  • LV dysfunction → blood backing up → ^ LA psi → ^ pulmonary venous psi → ^ hydrostatic psi → goes to alvoli

• Noncardiogenic: ^ permeability

  • lung injury, ARDS, pneumonia, sepsis, trauma, TRALI, high altitude

S/s:

• SSOB, ^ RR, hypoxia, distress

• Anxiety, gasping for air, pink frofthy sputum

• Sweating, dizzy

• Cyanosis of lips

• HTN & JVD

• V BP may signify cardiogenic shock

D/x:

• C-XRAY: checks for effusion & infilitrates

• PCWP:

  • High = cardiogenic

  • Normal = noncardiogenic

T/x:

• Fowlers, O2 support, Loop diuretics

• Monitor electrolyes

• Add nitro if ordered

Pneumothorax: Air in pleural activity → ^ pulmonary psi → collapse

Types:

• Spontaneous:

  • PSP: unknown; young tall males

    • Leads to lung inflammation & stress

    • Severe pleuritic chest pain → shoulder, SOB

  • SSP:

    • From COPD & TB, CF, etc

• Traumatic:

  • Open: sucking chest sound

  • Iatrogenic; thoracentesis, biopsy, vent

• Tension:

  • Causes lung collapse, shift, vCO → shock risk

  • PAAP may lead to it

S/s:

• Chest pain, SOB, ^ RR, dyspnea, & HR, hypoxia

• Assymetrical expansion, v fremitus, hyperresonance

• Absent breath sounds

Tension s/s:

• Hypotension, JVD, tracheal deviation, Cyanosis, ^ HR

D/x:

• C-xray & E-FAST

T/x:

• Needle decompression (14-16 ghz) → 2nd ICS midclavicular line

• Chest tube

Hemothorax:

• Blood in pleural space from blunt/penetrating trauma → bleeds to chest

• May cause v ventilation & hypoxia & hypovolemia → v CO → shock risk & cardiac arrest

S/s:

• SOB, resp distress, ^ RR, ^ HR, v BP, absent breath sounds, asymmetrical breath sounds

• Dull percussion

• JVD

D/x:

• C-xray, E-FAST

T/x:

• High conc O2 + 2 large bore IVs

• Remove blood via 28-32 french thoracostomy

• Analgesics & position in fowlers

• Chest tube:

  • A/x drainage, #, pattern, VS, bubbling patterns

Digestion & Bowel

General roles:

Pancreas (Exocrine):

• Amylase, Protease, Lipase,

• Pepsin: released in stomach when acid levels are high

• Trypsin help break down proteins

Liver:

• breaks down RBCs

• Regulates chemical makeup of blood

• Detoxifies, Absorbs Vitamins

• Bile, produces protein & cholesterol

• Controls metabolic processes

GI:

• Duodenum: breaks down & absorbs lipids

  • Bicarb excreted here

• Jejunum: absobs sugars, aminos, & fatty

• Ileum: absorbs Vb12

• Brush border: epithilial layer of s.i.

• Colon:

  • Absorbs water & salt

Oral conditions ALL LEAD TO MALNUTRITION

Oral HSV-1:

• Produces lesions in lips during stressful or v i.s. moments or older age or close quarter living

• Cold sores (fluid-filled pimples) → crust & dry over days

• Malaise, sore throat, swollen lymph, flu-like

  • Fever may happen before lesions appear

• T/x:

  • Warm or cold compreses

  • Use warm water or rinses for open lesions

  • OTC creams, antivirals (acyclovir), ibuprofen

Oral aphthosis (canker sores):

• lasts 7-10 days

• R/x:

  • Menstruation, stress, spicy food, biting

Oral Candidiasis:

• Raised patches/coating inside cheek → issues eating & mouth pain or irritation

• Coritcosteroids → immunosuppress

Periodontal disease: inflammatory condition from bacteria plaque → gingivitis & tooth decay

• May lead to teeth separation & bad breath → oral cancer

• D/x:

  • measure depth of teeth separation

Oral Cancer:

• Smoking, tobacco, alcohol, poor hygiene, HPV, poor SDOH

• S/S:

  • Mouth pain, lump, white patches, sores that done heal, lymph raised, hoarse voice, weight loss

Barret Esophagus:

• GERD causes normal cells to turn into goblet cells

• Heartburn, dysphagia, sore throat, bad breath, v weight, bloody stools

• D/x:

  • Do a EGD or tissue bipposy

• T/x:

  • Eat small frequent meals >3x/day

  • PPI (-prazole)

    • A/E:

      • C-diff, osteoporosis

      • Lower absorption of Ca, Mg, VB12

  • H12 receptors (-tidine)

  • Antacids

  • Baclofen → relax LES

GERD:

• Acid travels to stomach → irritates lining → stricture formation → sensation of food being stuck → dry, v urine output, dizzy, tachy, v BP (all severe)

  • Burning sensation, throat irritation, chest pain

  • Dysphagia, Dyspepsia, Odynophagia, Hoarse, cough, N/V

• Spicy foods, smoking, obesity, & sedentery may increase risk

• Watch out for H.Pylori bacteria, C-diff & tight clothing

• May cause halitosis

• Dehydration risk & malnutrition

D/x:

• EGC

• Catheter method

Edu:

• Sleep on left side

• Good oral hygiene

• Sleepw/ extra pillow bellow bed

T/x:

• Take H2, PPI, Antacids

• Anrireflux surgery

• Nissen Fundoplication: wrap stomach around LES

Hiatal Hernia: Intra abd psi pushes stomach over diaphargm → GERD like s/s

• Heartburn, regurgitation, chest pain, nauses

• May worsen GERD when eating triggering foods

• Dehydration & Malnutrition risk

• Types:

  • Sliding

  • Paraesophagel: rarer, wors

• Worsens cancer & Barrett risk

R/x:

• Prengancies, COPD, muscle weakness, constipation

s/s:

• Heartburn, regurgitation, sour taste, dysphagia, N/V, hoarse, chronic cough

• Feeling full

• Volvulus; feeling full

• Cameron lesions: mechanical erosion which causes occult blood loss

D/x:

• EGD, barium

T/x:

• H2, PPI, Antacids

• Laparoscopic NIssen Fundoplication (LNF)

Gastroparesis: chronic disorder caused by neurological dysfunction that leads to delayed gastric emptign

• Due to vagus never or gastric pacemaker cell issues

S/s:

• N, vomiting, bloating, abd pain

• Early satiety, acid reflux, weight loss, X appetite

R/x:

• Poorly controlled DM or surgery to vagus nerve

• Opioid or antidepressants

PUD t/x:

• PPI, H2, Antacids

• v NSAIDS

• Misoprostol:

  • v acid & ^ mucus

• H pylori:

  • 2 antibiotis + 1 acid suppression

• Vagotomy: v gastric acid secretion

IBS: no path but it its like a ruled out condition

• Hypersensitivity in GI nerves → cramps, abd pain, bloating, diarrhea/constipation, gas

• Common in females & when stressed

• s/s:

  • Uncontrollable/violent diarrhea or consitpation (either/or)

  • Abd cramping, bloating, fart, bloody stools

• Lower stress, avoid trigger foods, stay hydrated, lock in & sleep

IBD:

• Chrons & UC

• Utilize v fiber during flareups

• Avoid gassy foods

Chrons:

• Deeper layers of GI; mouth → anus

• Cigarretee smoking, AXA exposure

• s/s:

  • Diarrhea, rectal bleeding, abd pain, v appetite

  • Abscess or fistulas

UC:

• colon & rectum → small sores

• S/s:

  • Stool urgency, fatigue, mucous in stools, blood stools

  • Nocturnal sharting

Possible ostomies

Bowel obstruction:

• most are small and due to intra-abdominal adhesions

• s/s:

  • Sharp pain, distention, diarrhea or no stools, N/V

  • Diarrhea may be early on

R/x:

• Prior surgeies, IBD, tumors, impacted shite, hernias

• Partial:

  • take laxatives

• Complete:

  • give IV fluids, NG tube, analgeiscs & antinausea meds

DiverticulosisL in weak points of sigmoid colon

• ^ fiber in both

• Itis → infection

  • S/s:

    • Abd pain, n/v, fever, tender

    • Abscess, fistula → peritonitis

R/x:

• older age, obese, smoking, low residue diet

• Taking steroids, opioids, NSAIDs

Celiac Disease:

• Reaction to gluten → dmgs s.i. lining → malabsorption

• ^ CNS risk → headaches & seizures

• s/s:

  • Diarrhea, fatigue, v weight

  • Bloating, anemia

  • Lactose intolerance

  • Neuropathy, joint pain, & v bone density

  • v function of spleen

• d/x:

  • Tg-IGA testing

R/x:

• Family h/x, T1DM, down syndrome

Intestina conditions:

• May lead to v weight, cramping

• mouth sores, dermatitis, joint pain

• Osteoporosis, malnutrition

Intestinal t/x:

• Meds:

  • Psyllium: absorbs lquids & bulks stool; for diarrhea & constipation

    • Take w/8oz water; may take days to work

    • eat high fiber

  • Laxatives: MIlk of Mg or Miralax

    • ^ bulk & keep fluids

    • For constipation

  • Corticosteroids & Amonosalicylates

    • v intestinal inflammation during flareups

    • Take in mornign & w/glass of water

  • Biologics: -mab

    • lowers inflammatory producing proteins → IBD

Kidneys

Kidney function:

• Remvoes waste

• Regulates pH via

  • H+ & HCO3

    • Prominent in resp acidosis

• Maintains osmolarity & E+ balance

• Makes:

  • Erythropoetin

  • Renin

• Turns VD → Calcitiriol

Patho:

• Renal artery → afferent → glomerulus → bowman capsule → efferent →venous

Labs:

• BUN: a/x kidney function & dehydration

  • 10-20

• Cr: waste product from muscle use

  • 0.6-1.2

UTI:

• E-coli is most common along w/catheter use (CAUTI)

  • due to biofilm formation on catheter & ascension after

• Untreated may lead to urosepsis

  • Take estrogen vaginal cream for uncettes

S/s:

• Urgency, frequency, dysuria, hematuria, nocturia, no full empting

• Suprapubic pain

• Kidney:

  • Flank pain, N/V, fever/chills

• Bladder:

  • hematuria, pelvic pain, frequency

• Urethra:

  • Discharge, burning

D/x:

• Urinalysis → checks color, pH, WBCs, nitrites, blood in urine

  • Nitrites checked because E-coli converts nitrates → nitrites

• Urine coulture

• CBC → ^ WBC

T/x:

• AXAs

• Cranberry

  • Not for CAUTI as it cannot stop biofilm formation

• Hydration & hygiene

Incontinence:

Types:

• Stress:

  • coughing, sneezing, laughing

• Urge:

  • Overactive detrusor mmuscle → leakage & urugency

• Overflow:

  • Overdistended bladder → weak muscles

  • From Pelvic prolapse, BPH

    • Childbirth, coughing, age, obese, heavy lifting

R/x:

• ETOH, caffeine, spicy, sugar, choco, sodas

• Diuretics, A lockers, SSRIs, Opioids

D/x:

• Urinalysis

• Stress test: coughing w/full bladder

• Bladder scan: >PVR 200 mL → overflow incontinense

  • <50= normal

  • 400+ = retention

T/x:

• Bladder training, kegel, scheduled voiding

• X smoke, ETOH, caffeine, fluids at night

Retention

• From:

  • BPH, POP, stones, strictures

  • MS, Parkinons, Stroke, SCI, DM

  • SSRIs, Opioids, NSAIDs

S/s:

• Slow stream, no full emptying

• Acute:

  • Lower abd pain, distention

• May lead to: UTI, Kidney, stones, sepsis

T/x:

• Catheterization, Bladder scans, I&Os

• self-caht teaching

• Double voiding meta

BPH:

• leads to retention

• testosterone → DHT → ^ prostate size

• Males >50, fat, Metabolic Syndrome

D/x:

• Digital rectal exam

• PSA screening

T/x:

• Alpha blockers (-osin) “tamsulosn, doxazosin”

• TURP: trimming away excess prostate

  • Monitor bleeding

  • Continuous bladder irrigation

  • I&O

  • 2-3 L fluid/day

  • Avoid heavy lifting for 4-6 weeks

Pyelonephritis:

R/x:

• Retention, female, stones

• Immunosuppressed, catheters

• DM → Emphysematous pyelonephritis → necrotizes kidney tissues

• s3xually active females & 2-3rd trimester

May lead to:

• Renal abscess, sepsis, shock, CKD

S/s:

• Fever, flank/groin pain, dysuria, cloudy/bloody urine

• Fishy odor

• chills, N/V, fatigue, AMS

• CKD:

  • Fatigue, Prutirus, ankle edema

D/x:

• UA (nitrites etc.), culture, CBC,

  • If nitrites ound notify due to Emphysematous pyelonephritis risk

• US →cysts, tumors, obstruction

• DMSA → radioactive IV → renal scarring

Edu:

• Void after rizzing, X douche

• hydrate

• Tylenol, AXAs adherence

T/x:

• IV AXA initially → oral for 10-14 days

PKD: fluid cysts stay in kidney

• ADPKD: adults

  • leads → ESRD

• ARPKD: -prebirth

  • Leads to breathing difficulties

R/x:

• Family h/x

• not curable

Leads to:

• Cysts in liver/pancreas

• stones, cardiac disease

• Cerebral aneurysms

• Mitral valve prolapse, V hypertrophy, weakens b.v. → aneurysms

S/s:

• Flank pain, masses

• Poly,Noctu,Hema,Proteinuria

• → oliguria → ESRD → fluid overload

• Possible urine stasis → infection

D/x:

• US, CT,MRI

Edu:

• Low protein diet, v Na

• X smoking & NSAIDs

• ACE, ARBs, hydration

• Tolvaptan: to treat really v Na & for ADPKD

Glomerulonephritis

• Leads to protein & blood in urine

  • AND high BUN & Cr contents in blood

• May happen after Strep throat or impetigo or endocarditis or Hepatitis or HIV lol

  • or lupus, or goodpasture or Burger disease

  • typically happens AFTER a systemic infection

Patho:

• Streptococcus → inflammation → thickens glumerulus → v GFR ← antibodies attack glomerulus & new cells form in Bowman capsule

• Glomerulus dmgd → waste in blood stream → RBCs go to urine → Hypercholesteroemia, HTN, & edema

S/s:

• Periorbital edema

• Dark urine, ^ BP

• weak, fever, malaise

• Nephrotic syndrome

• Nephritic: less protein, more blood & HTN

• TRIAD:

  • Oliguria + edema + HTN

D/x:

• ^ K, ^ BUN, ^ Cr, v GFR, ^ specific gravity (>1.020)

• 24hr urine collection

• or biopsy

Edu:

• Take ur vaccines

• Understnad:

  • Strepthroart

  • Lupus

  • DM

  • Family h/x

  • NSAIDs

T/x:

• Prednisoone

• Rituximab

• Cyclophosphamid → cytotoxic med used w/steroids

• BP meds

Stones:

• leads to pain & blood in urine

• pH<7.2 → oxalate

• phophate ← alkaline

R/x:

• Age, males, obese, heat exposure

• high protein diety wCa & NaCl

• ^PTH → takes Ca from bones → stones

• Stress, A/D

S/s:

• Flank pain, N/V

• if systemic → pyelonephritis

D/x:

• UA, CBC, Kidney test

• A/x for ^ Ca, Uric acid, & PTH

• Xray & US

• Filter test

T/x:

• <5mm → nothing

  • Tamsulosin, Alfuzosin, Nifedipine

• ESWL

• ^ water, v Ca & purine foods & protein & sodium

AKI:

• Prerenal: v b.f. → kidney

• Intrarenal: dmg to kidney tissue

  • Acute tubular necrosis

    • nephrotoxic meds

    • dyes, aminoglycosides

    • Rhabdomyolosis, lupus

    • May be before sepsis or ischemic event

    • Hypotension r/x

• Postrenal: cannot go to tract

  • BPH, mass, clot, neurogenic bladder, stones

R/x:

• Hospitalized pts

  • More monitoring for vanco

S/s:

• A/D

• Oliguria, edema, SOB

• HTN, pulmonary edema, HF, possible cardiac arrest

• N/V, poor sleep, confusion

• Possible hypovolemia

Polyuria, nocturia & pruritus are MORE common in CKD > AKI

D/x:

• Cr, GFR, BUN

Edu:

• Hemodialysis

• v Na, K, P, fluids