NSG2NCI Nursing Patients With Chronic Illness

1. The most likely chronic disease that fits and symptoms and history of the patient:

The patient (Mr Bob Jackson, aged 55 years) was admitted to the emergency department with a complaint of diarrhoea, nausea and malaise. He was suffering from a Left Lower Quadrant pain and diarrhoea for the last 1 week. He has a medical history of obesity, hypertension, seasonal rhinitis, arterial fibrillation, depression and osteoarthritis. Clinical examination revealed that he has a distension of the lower abdomen, soft and tender abdomen in the lower left quarter, mild obesity and increase in pain while moving.

The symptoms of diarrhoea, nausea, malaise, blood in the stool, pain and tenderness in the left lower quadrant and pain while moving can be related to diverticulitis. The diagnosis of diverticulitis can also be supported by his history of obesity and hypertension (Sallinen et al. 2015). It is known that patients suffering from diverticulitis show signs of frank blood in the stool, experience pain in the left lower quadrant of the abdomen and feeling of nausea and malaise and also might have tenderness and dissention of the lower abdomen, all of which were also seen in case of Mr Jackson. The patient is also a regular smoker which is also known to increase the risks of diverticulitis. This suggests that the patient might be suffering from diverticulitis (Kvasnovsky & Papagrigoriadis, 2015).

Etiology and Pathophysiology of the disease that can justify the patient condition:

Diverticulitis or diverticular disease is a condition where the pouches or diverticular in the intestine can get inflamed or infected. The inflammation can be caused due to infection spreading to the diverticular and can lead to perforations of the bowel. This can lead to intense pain, especially in the lower left side of the abdomen as seen with the patient. Studies have shown that diverticulitis develops the same way ad appendicitis and the lumen of the diverticular gets inflammed and blocked thereby increasing the intraventricular pressure. The blockage can be caused due to fecal matter and further blockage is caused due to the formation of mucous (Tursi et al., 2015). This causes a proliferation of bacteria in the diverticulum leading to diverticulitis. The blockage and increase in the intradiverticular pressure can also lead to tenderness of the abdomen, which was also found in the patient during the clinical checkup (Schieffer et al., 2018). Also perforations can be caused due to diverticulitis which can increase pain in the abdomen, especially while movement as the perforated tissue comes in contact with the adjoining organs. The symptoms of nausea and malaise can be attributed to dehydration cause due to the diarrhea, as the body loses fluids. Urine analysis of the patient showed a higher than normal specific gravity (due to higher content of solutes) which can point towards dehydration (Rezapour & Stollman, 2018).

Diverticulitis can be caused due to several factors such as obesity, low fiber diet, smoking and age. The patient has a history of obesity and is a heavy smoker which might be the cause of his condition (Tartaglia et al., 2016; Ma et al., 2018). Also his age (55 years) and gender (male) can also have increased his risks of the condition. It is vital however to check the diet of the patient, whether he consumes enough fiber in his diet (Stam et al., 2017).

Any additional information about the patient that can support the diagnosis:

Since the patient is a sheep farmer from Melbourne, it might be assumed that he might be physically active in his work, but also might point out towards a high protein and low fibre diet that is common among sheep farmers. Also, the risks of diverticulitis increase with age and are more significant in males than in females. Additionally, due to osteoarthritis, the patient’s movement might be restricted which might limit his physical activities thereby increasing his risks of diverticulitis. It is important therefore to comprehensively assess his lifestyle (such as daily physical activity and diet) to understand if they are related to the patient’s condition. Appendicitis can be ruled out for the patient since he already had his appendix removed during childhood (Mosadeghi et al., 2015; Tate, 2014).

2. An alternate diagnosis that can also explain the patient condition:

Considering the patient condition another diagnosis that can be related to the patient condition is inguinal hernia, which can also cause distension of the abdominal wall, pain, nausea and sometimes diarrhoea. Hernia can also cause pain while movement and can be caused due to lifestyle factors as well as obesity (White et al., 2016).

Clinical data that can help to discriminate the two diagnoses:

Since the patient’s condition can be linked to both Diverticulitis and Hernia, it is important to differentiate these two conditions to identify which condition is causing the symptoms in order to treat the patient effectively. Tests that can help to differentiate between the two conditions are:

White Blood Cell Count: This can help to identify signs of infection. A rise in the white blood cell count can increase due to an infection, when the body tries to fight the invading pathogens. The increase in the white blood cell leads to inflammations which are seen in case of diverticulitis. To count the white blood cell content, blood test needs to be done. If the WBC count is higher than normal, it can point towards a possible infection and thus diverticulitis and hernia can be ruled out. Since in case of hernia, there is no infection involved, it rarely causes increase in the WBC count (van Tol et al., 2016)

Physical Exam: This is an important strategy that can help to differentiate between inguinal hernia and diverticulitis. In case of hernia, the distension is generally in the region of the groin, or below the lower quadrant of the abdomen, and in case of diverticulitis the distension is in the region above the groin. The physical examination of the patient showed the distension was in the lower left quadrant which pointed towards diverticulitis. However the inguinal canal should be examined to confirm the patient is not suffering from inguinal hernia (Guarino et al., 2018).

CT scan: Diverticulitis can be identified through CT scans, and is visibly identifiable by out pouches of the colonic wall. The out pouches might be filled with air or faecal matter, which can be seen in the CT Scan Image. The scan can also show signs of paracolic and colonic inflammation which can be the sign of diverticulitis. However in case of hernia, the CT scan would show distension in the groin region. In such case, inflammation of the diverticula would not be seen (Ou et al., 2015).

Ultrasonography: This can also be used apart from CT scan to find out abnormalities in the abdominal lining and abdominal region. In case of diverticulitis, inflammation can be found in the diverticulum, while in case of hernia, the diverticulum would look normal, but a bulge can be seen near the groin muscles (Maconi et al., 2016).

Urine Test: Urine test can help to identify signs of infection and thus understand if the patient is suffering from diverticulitis. The patient’s urine analysis showed that it had a higher specific gravity which pointed out towards possible dehydration as the urine contains a higher concentration of solutes, which can be due to diarrhoea (Enemchukwu et al., 2015).

Liver Function Test: Liver function test can help to eliminate the cause of the abdominal pain and diarrhoea from other liver related conditions which can also cause similar symptoms in the patient. Presence of any liver abnormalities, which can be found through the concentrations of bilirubin, biliverdin, SGPT and SGOT can eliminate the possibility of diverticulitis (Ho & Apollos, 2016).

Stool Test: Stool test can be used to identify whether the patient has any infections which might get passed in the stool. Analysis of the stool can show any pathogens that might be present in the alimentary canal and thus pointing out towards diverticulitis. Absence of any infections can point out towards hernia or other non-infective causes of the abdominal pain (Kvasnovsky & Papagrigoriadis, 2015).

References:

Enemchukwu, E., Lai, C., Reynolds, W. S., Kaufman, M., & Dmochowski, R. (2015). Autologous pubovaginal sling for the treatment of concomitant female urethral diverticula and stress urinary incontinence. Urology, 85(6), 1300-1303.

Guarino, S., Verardi, F. M., Romiti, A., Eusebi, L. H., Bazzoli, F., Cavazza, M., & Zagari, R. M. (2018). P. 05.18 Clinical Evaluation Of Non-Traumatic Acute Abdominal Pain In The Emergency Department: How Do Physicians Collect Pain Characteristics And Perform Physical Examinations?. Digestive and Liver Disease, 50(2), e173.

Ho, W., & Apollos, J. (2016). Is periampullary diverticulum associated with failed CBD cannulation and pre-ercp liver biochemistry?. International Journal of Surgery, 36, S116-S117.

Kvasnovsky, C. L., & Papagrigoriadis, S. (2015). Symptoms in patients with diverticular disease should not be labelled as IBS. International journal of colorectal disease, 30(7), 995-995.

Ma, W., Jovani, M., Liu, P. H., Nguyen, L. H., Cao, Y., Tam, I., … & Chan, A. T. (2018). Sa1070-Obesity, Weight Change and Risk of Diverticulitis: A Prospective Cohort Study in Women. Gastroenterology, 154(6), S-229.

Maconi, G., Carmagnola, S., & Guzowski, T. (2016). Intestinal Ultrasonography in the Diagnosis and Management of Colonic Diverticular Disease. Journal of clinical gastroenterology, 50, S20-S22.

Mosadeghi, S., Bhuket, T., & Stollman, N. (2015). Diverticular disease: evolving concepts in classification, presentation, and management. Current opinion in gastroenterology, 31(1), 50-55.

Ou, G., Rosenfeld, G., Brown, J., Chan, N., Hong, T., Lim, H., & Bressler, B. (2015). Colonoscopy after CT-diagnosed acute diverticulitis: Is it really necessary?. Canadian Journal of Surgery, 58(4), 226.

Rezapour, M., Ali, S., & Stollman, N. (2018). Diverticular disease: an update on pathogenesis and management. Gut and liver, 12(2), 125.

Sallinen, V. J., Leppäniemi, A. K., & Mentula, P. J. (2015). Staging of acute diverticulitis based on clinical, radiologic, and physiologic parameters. Journal of Trauma and Acute Care Surgery, 78(3), 543-551.

Schieffer, K. M., Kline, B. P., Yochum, G. S., & Koltun, W. A. (2018). Pathophysiology of diverticular disease. Expert review of gastroenterology & hepatology, 12(7), 683-692.

Stam, M. A. W., Draaisma, W. A., van de Wall, B. J. M., Bolkenstein, H. E., Consten, E. C. J., & Broeders, I. A. M. J. (2017). An unrestricted diet for uncomplicated diverticulitis is safe: results of a prospective diverticulitis diet study. Colorectal Disease, 19(4), 372-377.

Tartaglia, D., Coli, V., Arces, F., Raffaele, S., Bertolucci, A., Modesti, M., … & Chiarugi, M. (2016). Age, BMI and severity of acute diverticulitis: myths or facts?. Journal Of Clinical Gastroenterology.

Tate, D. (2014). Abdominal mass/hepatosplenomegaly. Acute Medicine, 1.

Tursi, A., Papa, A., & Danese, S. (2015). the pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Alimentary pharmacology & therapeutics, 42(6), 664-684.

van Tol, R. R., Breukink, S. O., Lahaye, M. J., & Derikx, J. P. M. (2016). Inclusion of C-Reactive Protein and White Blood Cell Count in Diagnostic Workup of Patients with Clinically Suspected Appendicitis Stratifies for Imaging. J Med Diagn Meth, 5(212), 2.

White, T. L., Scheiner, J., & Picon, A. I. (2016). Retained Percutaneous Endoscopic Gastrostomy Causing Small Bowel Obstruction in Inguinal Hernia. The American Surgeon, 82(5), E101.