GI, GU, STD Disorders

Allotted time:

Instructional references:

Terminal learning objectives: Given a simulated patient with simulated symptoms, the student will be able to recognize potential problems and properly perform needed exam.

Enabling learning objective:

  1. The student will be able to identify the different disorders of the gastrointestinal and genitourinary system.

  2. The student will be able to identify the signs and symptoms of GI, GU, & STD disorders.

  3. The student will be able to identify different types of sexually transmitted diseases and their causative agent.

  4. Be able to identify the treatment of GI, GU, & STD disorders.

 

  1. Gastrointestinal Disorders

    1. Acute simple gastritis
      1. signs/symptoms
        1. malaise
        2. anorexia
        3. epigastric pressure
        4. headache
        5. dizziness
        6. nausea/vomiting
        7. last for approx. 24-48 hours
        8. possible mild epigastric tenderness

      2. Treatment
        1. remove offending agent, such as food or medications
        2. use antacids to coat the stomach
        3. NPO if you suspect appendicitis
        4. give Phenergan 25mg IM/IV and IV fluids per MO order
        5. most patients will respond to antacids
        6. IV therapy to correct electrolyte inbalance if not tolerating oral fluids
        7. Above all, maintain hydration.

    2. Gastroenteritis
      1. signs/symptoms
        1. anorexia
        2. nausea and vomiting
        3. diarrhea
        4. abdominal cramps
        5. malaise
        6. myalgias
        7. severe dehydration and shock possible
        8. abdomen distended and tender
        9. fever

      2. treatment
        1. bed rest with bathroom access
        2. clear liquid diet, maintain hydration
        3. IV rehydration with compazine/phenergan if needed
        4. follow up in 24 hours

    3. Appendicitis
      1. signs/symptoms
        1. Mild to severe pain in epigastric or peri-umbilical area. Usually gets pain before vomiting.
        2. may have only one to two episodes of vomiting
        3. pain shifts to RLQ after 2-12 hours
        4. increased pace of soreness with walking, coughing, sneezing, or any jarring motions.
        5. may mimic gastroenteritis, but pain will move to RLQ
        6. may have loss of appetite
        7. may have slightly elevated temperature, 99-102 degrees
        8. moderate malaise
        9. constipation with rebound tenderness in RLQ
        10. pain is not always located in the classic position
        11. pain may make patient wish to stay still. Having the patient move may be difficult.

      2. treatment (if appendicitis is suspected refer to MO)
        1. observation
        2. NPO/bed rest
        3. NG tube per MO order
        4. refer to MO
        5. no laxatives or narcotics
        6. IV ringers lactate
        7. surgery required

    4. Diarrhea (an increase in stool frequency or volume)
      1. signs/symptoms
        1. change in consistency
        2. blood
        3. mucus
        4. pus
        5. fatty materials, oil, grease (stools will float if high in fat)

      2. etiology
        1. can be caused by nerves, viral, or bacterial infection
        2. nocturnal diarrhea may suggest organic disease of the bowel
        3. may be found in family history of GI disorders
        4. different food or water as in history of travel
        5. poor water or food sanitation or poor hygiene
        6. may have fever associated with dehydration

      3. treatment
        1. dictated by cause when known
        2. clear liquids for 24 hours, then diet as tolerated
        3. Kaopectate indicated only if illness and diarrhea continues
        4. may give Lomotil or Imodium if no blood in stool or no fever
        5. if febrile or blood in stool, refer to MO for antibiotic and stool culture

    5. Constipation (difficult or infrequent passage of feces)
      1. can refer to:
        1. hardness and difficulty in defecation
        2. feeling of incomplete defecation
        3. can present as an acute abdomen
        4. can be caused by decrease in fluid intake in excess of two days, causing a hard dry stool.
        5. normal defecation varies from TID to q 3 days

      2. treatment
        1. reeducate patient as to diet and fluid volumes
        2. breestablish regular evacuation
        3. have patient drink 6-8 glasses of water
        4. metamucil 3 tbsp bid with plenty of water
        5. never give a laxative if you suspect an acute abdomen
    6. Inguinal Hernia
      1. etiology
        1. can be congenital
        2. caused from acute or chronic abdominal strain (i.e., lifting heavy weights, chronic constipation)

      2. Two types:
        1. Indirect - bowel protrudes through the external inguinal ring
        2. direct - bowel protrudes through the posterior wall of the inguinal canal

      3. Signs/symptoms
        1. heavy dragging sensation in groin
        2. local tenderness with sudden straining
        3. may find large inguinal mass in exam of scrotum
        4. thumb test hernia examination

      4. Treatment
        1. moist heat may provide some relief of discomfort
        2. slight maneuver pressure for reduction (MO only)
        3. always refer to MO for surgical consult

      5. Complication
        1. Incarceration - cannot be reduced by patient or manipulation
        2. Strangulation - blood supply interrupted
        3. if either occurs or suspected, refer to MO, STAT surgery is indicated

    7. Hemorrhoid (piles-vari cosities or the blood vessels in the rectal passage or anus. Can be external or internal).

      1. etiology
        1. occurs with straining during bowel movement, chronic constipation, prolonged sitting, pregnancy and hereditary

      2. signs/symptoms
        1. burning, itching sensation following defecation
        2. bright red blood noted when wiping
        3. severe pain and tenderness may indicate thrombosis of hemorrhoid and require I&D

      3. treatment
        1. high roughage diet / Metamucil 2 tbsp bid
        2. establish regular bowel habits
        3. sitz baths for relief of pain
        4. suppositories
        5. topical anesthesia
        6. surgery for severe cases
        7. refer to MO if above treatments fail

  2. Genitourinary disorders

    1. Basic exam
      1. penis
        1. inspect skin, foreskin, glans
        2. palpate shaft for tenderness or induration
      2. scrotum
        1. inspect contour and anterior/posterior sides
        2. palpate noted lumps, swelling, size, shape, consistency, or tenderness

    2. Disorders
      1. cystitis: is a bladder infection resulting from bacteria entering the bladder via the ureters or urethra

        1. signs/symptoms
          1. hematuria - gross or microscopic
          2. frequent urination
          3. dysuria
          4. urgency
          5. nocturia

        2. diagnosis
          1. routine U/A
          2. do clean catch
          3. C&S of urine

        3. treatment
          1. antibiotics
          2. refer to MO
          3. test to r/o venereal diseases

      2. prostatitis: bacterial infection of the prostate
        1. signs/symptoms
          1. high fever/chills
          2. urinary frequency and urgency
          3. perineal and low back pain
          4. dysuria and possible urinary retention
          5. may be gross hematuria
          6. prostatic examination (rectal) may show warm, tender, locally and diffusely swollen or indurated prostate (boggy)

        2. diagnosis
          1. U/A
          2. C&S of urine
          3. refer to MO

        3. treatment
          1. may require hospitalization and bed rest
          2. analgesics
          3. IV antibiotics for sepsis
          4. Bactrim DS 1 tab bid X 20 days or Cipro 500mg bid X 20 days in outpatient therapy
          5. hot sitz baths, frequent ejaculation, abstinence from caffeine and alcohol

      3. chronic prostatitis (bacterial or nonbacterial)
        1. signs/symptoms
          1. usually asymptomatic
          2. rectal exam
          3. urethral secretions
          4. U/A reveals TN TC WBC’s in clumps in secretions
          5. micro or macroscopic hematuria

        2. diagnosis
          1. C&S will reveal no pathogens in urethral, bladder, & prostatic secretions in chronic nonbacterial prostatitis

        3. treatment
          1. always refer to MO
          2. hot sitz baths
          3. order C&S on urine and urethral, bladder, and prostatic secretions
          4. both bacterial and nonbacterial types improve with antibiotics

      4. acute bacterial epididymitis: is usually a complication of bacterial urethritis or prostatitis. In sexually active males less than 35 y/o, it is most likely caused by N. Gonorrhea or C. Trachomatis

        1. signs/symptoms
          1. almost always unilateral
          2. need to r/o torsion testicle
          3. fever and pain
          4. swelling and induration
          5. tenderness

        2. diagnosis
          1. C&S of urine
          2. physical exam

        3. treatment
          1. bed rest
          2. scrotal support
          3. scrotal elevation
          4. ice packs
          5. analgesics
          6. frequent ejaculations
          7. DOC, Vibramycin 100mg bid X10-14 days and add Ceftriaxone (Rocephin) 250mg IM once in males less than 35 y/o
          8. test to r/o GC/chlamydial infections

      5. ureteral (renal) calculi
        1. sign/symptom
          1. back pain/CVA tenderness
          2. colicky pain
          3. GI symptoms
          4. hematuria, usually macroscopic, possibly microscopic
          5. urinary frequency

        2. diagnosis
          1. patient history of onset of pain, x-ray and U/A
          2. r/o differential diagnosis of appendicitis, cholecystitis, peptic ulcer, and pancreatitis

        3. treatment
          1. refer to MO

  3. Sexually transmitted diseases

    1. gonorrhea
      • total 2 million cases a year
      • very contagious, sometimes painful
      • etiologic agent: neisseria gonorrhea
      • mode of transmission is by sexual contact
      • often also infected with Chlamydia, empirically treat both
      1. signs/symptoms
        1. males
          1. urethral discharge, 2-14 days after exposure
          2. dysuria

        2. females
          1. almost always asymptomatic, may lead to P.I.D.
          2. usually has discharge from vagina/cervix
          3. dysuria

        3. both sexes
          1. may cause septic arthritis, gonococcal dermatitis
          2. other serious illness or death

      2. diagnosis
        1. requires gram stain, males only
        2. females may be cultured

      3. treatment
        1. Rocephin (Ceftriaxone) 250mg IM plus Vibramycin 100mg bid x 7 days or Azithromycin 1.0 gm PO (one time dosage)
        2. for PCN allergic pts, Spectinomycin 2mg, IM plus Vibramycin 100mg x 7 days

    2. syphilis
      • 325,000 cases a year
      • spread through sexual contact
      • etiologic agent: Traponema Pallidum

      1. signs/symptoms
        1. chancre, primary syphilis
          1. a painless sore that appears at the exposed area and around sex organ
          2. sore usually infects other sexual contacts
          3. occurs in the primary stage
          4. appears 21-90 days after contact
          5. resolves without treatment but person is still infected

        2. secondary syphilis
          1. occurs usually 6-8 weeks after chancre appears
          2. rash on any part of the body especially palms of hands and soles of feet
          3. balding spots
          4. fever, sore throat
          5. severe, recurring headache
          6. symptoms will disappear but person is still infected

        3. tertiary syphilis
          1. symptoms may occur right away 0r 10-25 years later
          2. tissue destruction
          3. loss of hair
          4. heart failure
          5. insanity
          6. deformity of bones

        4. congenital syphilis: is passed from the infected mother to child during birth
          1. blindness of infant
          2. infant may be born with or develop deformities
          3. death or still birth

        5. neurosyphilis
          1. can occur at any age
          2. early signs/symptoms include optic and auditory symptoms, cranial nerve paralysis
          3. requires a spinal tap for evaluation

      2. diagnosis
        1. VDRL/RPR
        2. presence of T. Pallidum seen under dark field microscope
        3. FTA/ABS final diagnosis
        4. damage that has occurred is permanent

      3. treatment
        1. Penicillin is the antibiotic of choice for all stages of syphilis.
          • Benzathine penicillin G 2.4 million u. IM produces satisfactory blood levels for 2 weeks (usually 1.2 million u. is given each buttock)
          • Two additional injections of 2.4 million u. q 7 days should be given for secondary syphilis because of treponemal persistance in the CSF of some patients after single dose regimens.
          • PCN allergic, give E-mycin 500 mg orally q 6 h for 15 days or Tetracycline (at same dosage) may be used. Pt compliance should be monitored closely.

    3. Lymphogranuloma venerum (LGV)
      1. spread through sexual contact
      2. etiologic agent: Chlamydia Trachomatis
      3. signs/symptoms
        1. incubation period is 5-21 days to primary lesions
        2. inguinal lymphadenopathy is most common clinical manifestation
      4. diagnosis
        1. enzyme linked immunosorbent assay (elisa)
      5. treatment
        1. doxycycline 100mg bid x 21 days or Azithromycin 1.0 gm PO (one dose)
        2. alternative tx is E-mycin 500mg qid for 21 days or sulfisoxazole 500mgPO qid x 21 days

    4. Herpes Progenitalis, genital herpes
      1. transmitted by sexual contact
      2. etiologic agent: herpes simplex virus
      3. signs/symptoms
        1. itching
        2. small red papules appear 2-8 days after sexual contact. Usually several papules appear which develop into tiny blisters.
        3. After 10 days from first appearance, crusting occurs, infection and pain subsides, healing then follows.
        4. During first 10 days, fever and swelling of the lymph nodes in the groin occurs
        5. The organism takes up permanent residence at the base of the spinal cord (dermatone)
        6. recurrent episodes caused by:
          1. trauma
          2. sexual intercourse
          3. emotional stress
          4. infection
          5. alterations in the body’s physiology

      4. diagnosis
        1. determined by a slide specimen of papule aspirate, tzank smear

      5. treatment
        1. no cure at present
        2. treatment of symptoms
          1. Do not give serum globulin or steroids, both may cause infection to spread
          2. strict cleanliness
          3. Acyclovir 200mg q4h 5 times daily (new - Valcyclovir)

    5. Chancroid
      1. Mode of transmission is direct contact with discharges from buboes or open lesions.

      2. etiologic agent - Haemophilus ducreyi

      3. signs/symptoms
        1. incubation period is 3-10 days, may be as short as 24hrs
        2. painful, necrotizing ulceration’s at site of inoculation
          1. pain, inflammation and swelling, and suppuration of regional lymph nodes in about 50% of cases

      4. diagnosis
        1. culture of exudate from edges of lesions, culture of pus from buboes

      5. treatment
        1. E-mycin 500mg qid x 7days or Ceftriaxone (Rocephin) 250mg IM in a single dose
        2. alternative treatment is Septra DS bid x 7days
        3. refer to MO

    6. Chlamydia - most common venereal disease
      1. 3-5 million cases reported
      2. sign/symptoms
        1. commonly occurs with GC
        2. can be asymptomatic, especially in women
      3. treatment
        1. Vibramycin 100mg bid x 7days or E-mycin 500mg qid x 7days or TCN 500mg qid for 7days or Azithromycin 1.0 gm PO (one dose)

    7. Non-gonococal urethritis
      1. etiologic agent - Chlamydia Trachomatis, Herpes Simplex, Trichomonas Vaginitis, Ureaplasma Urealyticum

      2. signs/symptoms
        1. burning on urination
        2. urethral discharge

      3. diagnosis
        1. urethral culture

      4. treatment
        1. uncomplicated: Tetracycline 500 mg PO q 6 hrs or Doxycycline 100 mg PO bid for 7 days
        2. complicated: require longer courses - Tetracycline 500 mg PO q 6 hrs or Doxycycline 100 mg PO bid for 21 to 28 days
        3. Pregnancy: substitute E-mycin 500 mg PO q 6 hrs for at least 7 days

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