Q-1

In this scenario, Mr. Green has come in with complaints of severe left lower abdominal pain lasting about two weeks with loose stools, which is aggravated by movement, and relieved by rest, and getting severely worse in the past two to three days. The patient denies any bloody stools. Patient has had a past medical history of colon cancer, with colon resection.

The patient takes a daily aspirin and multivitamin, and has been taking OTC ibuprofen for abdominal pain, also has had chemotherapy of 5-FU and leucovorin four years ago for one year. At this point, my working differential diagnosis is Cholecystitis, Appendicitis, Colon Cancer, Irritable bowel syndrome, Inflammatory Bowel Disease, Diarrhea, Peritonitis

During the interview and assessment it was discovered that the patient has had a past medical history including colon cancer and colon resection. It is possible that the patient could have developed peritonitis, or worse possibly a small perforation. Upon the assessment the patient was positive for abdominal pain in the left lower quadrant only, and his vital signs reveal he has a mild elevated temperature at 100.3 F. At this point my working diagnosis has dropped Cholecystitis and Appendicitis.

The new list includes Peritonitis, Diverticulitis, Irritable Bowel Syndrome, Inflammatory Bowel Disease, Colon Cancer, Diarrhea, and Perforation.

I wanted to order a CMP and CBC with diff, and the results came back within the normal range. At this point I wanted to investigate more in the abdomen, so first I ordered an Abdominal ultrasound. The abdominal ultrasound came back positive for enlarged, swollen diverticula, and was able to see inflammation processes localized in the left abdomen, moreso the lower left quadrant.

The patient’s HPI, interview, and assessment along with combining them with the tests, helped me to formulate the diagnosis of diverticulitis, and thinking more about it, the peritoneum is most likely inflamed as well, but diverticulitis is the etiology. Diverticulitis is a common disease process, occuring in about 40% of people over the age of 65, and with age and other comorbidities can also increase the incidence of diverticulitis (Linzay & Pandit, 2020). Diverticulitis can occur with painful abdomen locations usually in the lower left quadrant, and can present with diarrhea or constipation (Linzay & Pandit, 2020).

In the past, a CT of the abdomen with or without contrast, depending on kidney function, would have been the only accurate way to diagnose diverticulitis (Holladay, Fullmer, Peska, & Gottlieb, 2019). However, with recent advancements, ultrasound has quickly replaced the CT as a diagnosing tool for a multitude of reasons, but mostly for the decrease in cost and decrease in exposure to radiation (Holladay, Fullmer, Peska, & Gottlieb, 2019).

Keeping this in mind, I opted for an ultrasound instead of a CT scan, and it turns out that we were able to see enlarged diverticula which helped make a diagnosis. If the ultrasound was inconsistent or unable to view clearly, I would have ordered a follow up CT to be sure. After this, I decided to treat this on an outpatient basis, and have the patient begin bowel rest with a clear liquid diet. I also started him on Augmentin 875 PO BID for 7 days, and instructed him to call back if there was no improvement in 72 hours (Linzay & Pandit, 2020).

References: Holladay, D., Fullmer, R., Peska, G., & Gottlieb, M. (2019). Ultrasound for the Diagnosis of Diverticulitis: A Systematic Review and Meta-analysis…10th Mediterranean Emergency Medicine Congress, 22-25 September, 2019, Dubrovnik, Croatia. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 20, 1. Linzay, C.D., & Pandit, S. (2020) Acute Diverticulitis. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK459316/

Q-2

This week I have applied primary prevention strategies by educating patients on the importance of getting flu and pneumonia vaccine for their health. The patient was questioning if she should still get the vaccine and I had to explain that it can reduce complications of her COPD and that it is recommended that she still get both to protect herself from both flu and pneumonia.

Secondary prevention has been used with diagnosing patients with diabetes that didn’t know that they had it (Kisling, 2020). They got admitted to the hospital and their sugars were elevated so we decided to do an A1c on them and they were 7.5% which mad the patient a diabetic. We provided the patient with diabetic educator counseling, glucose monitoring education, and insulin administration education to help them with the new diagnosis (Bhattacharya, 2016). We also made sure the patient had a follow up appointment outpaietn to closely monitor them after discharge.

We had a discussion with the patient regarding the new diagnosis that lifestyle modification would have to be initiated and the diabetic educator helped reinforce this. We recommended that they walk more if possible, follow a diabetic diet, and monitor their sugars by keeping a log. Education is important in newly diagnosed diabetics that they monitor themselves for hyperglycemia and hypoglycemia. The signs and symptoms are important for them to know and what to do in that case of hyper or hypoglycemia. You want their glucose to be controlled to prevent microvascular/macrovascular complications.

Bhattacharya, P. K., & Roy, A. (2016). Primary prevention of diabetes mellitus: Current strategies and future trends. Italian Journal of Medicine, 10. doi:10.4081/itjm.2016.634

Kisling LA, M Das J. Prevention Strategies. [Updated 2020 Jun 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537222/

Q-3

Currently, my clinical rotation resides in a heavy geriatric patient population. COPD negatively impacts this specific population group as there’s a decline in lung capacity with advanced age increasing the risk of pneumonia, especially with the pandemic of COVID. COPD is a progressive lung disease that causes limitations in lung airflow and is most frequently diagnosed in adults ages 40 years and older, but it is preventable (Mannino & Make, 2015). As primary prevention, we provide the education of reducing or avoiding certain exposures. These include direct and indirect exposure to tobacco smoke, occupational exposures, irritants, and air pollution. Smoking cessation at 65 years of age leads to an increase in life expectancy of 1.4 to 2.0 years for men and 2.7 to 3.7 years for women (NCHS, 2018). The patients are also informed about a healthy lifestyle, such as a healthy diet and regular exercise to decrease risks.

In secondary prevention is early detection of COPD and intervention. For early detection, it is essential to do a comprehensive physiological assessment including lung function. According to the GOLD guidelines (2020), spirometry is required for diagnosis as post-bronchodilator FEV1/FVC <0.70 confirms airflow limitation. Additionally, early diagnosis may influence lifestyle modifications, such as smoking cessation. Pharmacotherapy and nicotine replacement increase long-term smoking abstinence rates. The pharmacological treatment regimen should be individualized and guided by several factors, such as the risk of exacerbations, side effects, comorbidities, drug costs, and patient’s preference. Short-acting beta-agonists (SABAs) are commonly used for mild COPD. Regular single-dose and PRN use of SABA or short-acting muscarinic antagonists (SAMA) can improve FEV1 and COPD symptoms, and a combination of both has a better outcome than either medication alone (GOLD, 2020). However, SABA should be utilized as PRN only as frequent usage can potentially lead to paradoxical bronchospasm and worsening the quality of life. Utilized in more moderate cases of COPD, LABAs and LAMAs can improve FEV1, reduce exacerbation rates, and improve the quality of life.

Tertiary prevention has focused on reducing exacerbations or improving symptoms in patients with COPD. The goals of COPD therapy include slowing the progression, initiating a smoking cessation plan, and ensuring the patient is up-to-date on vaccinations including influenza and pneumococcal. Adult patients, aged <65 years, with COPD, should receive the annual influenza vaccine as it reduces illness, such as lower respiratory tract infections, and the 23-valent pneumococcal polysaccharide vaccine (PPSV23), which reduces the incidence of community-acquired pneumonia (GOLD, 2020). Additionally, all adults need the Tdap vaccine to protect against whooping cough and tetanus.

References

Global Initiative for Chronic Obstructive Lung Disease. (2020). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf

Mannino, D. M., & Make, B. J. (2015). Is it time to move beyond the “O” in early COPD? European Respiratory Journal, 46, 1535-1537. https://doi.org/10.1183/13993003.01436-2015

National Center for Health Statistics. (2018). Health, United States, 2017: With special feature on mortality. https://www.cdc.gov/nchs/data/hus/hus17.pdf

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