Discussion w9 650

  

Instructions for Discussion Replies to 6 DQS

DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.

1- Each reply should be at least 200 words.

2- Minimum One Peer reviewed/scholarly reference ( NO MAYO CLINIC/ AHA)

3- APA 7th edition style needs to be followed.

4- Each response should have reference at the end of each reply

5- Reference should be within last 4 years

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

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

DQ-1

Hypertension and Renal Failure tend to be associated with one another, as an increased in blood pressure Is sustained, the arteries in the kidneys either narrow, weaken, or harden (Higashioka et al., 2016). Once this occurs, there is a decrease in adequate blood flow to the kidneys due to the damages of the arteries (Higashioka et al., 2016). Once there is a decrease in blood flow to the kidneys, the kidneys can no longer function properly, leading to renal failure or renal insufficiency (Higashioka et al., 2016). A classic sign of a decrease in functionality in the renal system is hyperkalemia due to decrease in renal functionality (Higashioka et al., 2016).

Another possible differential diagnosis for hyperkalemia is Renal Artery Stenosis with an etiology of Hypertension (Manaktala, Tafur-Soto & White, 2020). Hypertension as the etiology leads to atherosclerosis, and if atherosclerosis occurs at the renal arteries (amongst other arteries) the damage can be so immense that it can lead to renal failure by an upregulation of the renin-angiotensis-aldosterone system, which in turn creates a cumulative effect of continuously increasing hypertension (Manaktala, Tafur-Soto & White, 2020). The increase in hypertension can lead to a decrease in renal efficiency as described above, which can lead to renal failure and subsequently hyperkalemia (Manaktala, Tafur-Soto & White, 2020). 

These two differential diagnosis and the patient’s history of renal failure can make him a candidate for dialysis but only if he reaches a certain stage of kidney failure (Chronic Kidney Disease, 2018). This point happens over a long time of renal failure in a chronic condition, or quickly if there is an acute kidney failure (Chronic Kidney Disease, 2018). Usually there are two parameters; a GFR of <15, and in conjunction with symptoms of Uremia, itchy skin, peripheral edema, nausea, vomiting, loss of appetite, and a progressive loss of renal function (Chronic Kidney Disease, 2018). 

A diet that would help slow the progression of kidney disease or even help prevent dialysis would be a conscious diet that limits nutrients that are filtered by the kidneys (Chronic Kidney Disease, 2018). A diet that is low in salt, potassium, phosphorus, and protein would help decrease the rent to dialysis (Chronic Kidney Disease, 2018). Some common foods to avoid would be dark colored soda, avocados, canned foods, whole wheat bread, brown rice, and many others (Chronic Kidney Disease, 2018). 

References:

CHronic Kidney Disease (2018). Chronic Kidney Disease: When is the best time to start dialysis? Institute for Quality and Efficiency in Health Care: NCBI.NLM.NIH.GOV. 

https://www.ncbi.nlm.nih.gov/books/NBK492982/

Higashioka, K., Niiro, H., Yoshida, K., Oryoji, K., Kamada, K., Mizuki, S., & Yokota, E. (2016). Renal Insufficiency in Concert with Renin-angiotensin-aldosterone Inhibition Is a Major Risk Factor for Hyperkalemia Associated with Low-dose Trimethoprim-sulfamethoxazole in Adults. Internal Medicine (Tokyo, Japan), 55(5), 467–471. 

https://doi-org.lopes.idm.oclc.org/10.2169/internalmedicine.55.5697

Manaktala, R., Tafur-Soto, J. D., & White, C. J. (2020). Renal Artery Stenosis in the Patient with Hypertension: Prevalence, Impact and Management. Integrated Blood Pressure Control, 71. 

https://doi-org.lopes.idm.oclc.org/10.2147/IBPC.S248579

DQ-2

Hyperkalemia is a condition of electrolyte imbalance where the serum potassium level exceeds 5.5 meq/L. usually seen in chronic kidney failure patients, diabetes, heart failure, and use of certain medications such as renin-angiotensin-aldosterone system inhibitors and non-steroidal anti-inflammatory drugs (Montford, & Linas, 2017). The reason is due to a high level of extracellular potassium concentration, an additive, or a defect in elimination due to kidney failure, hyperglycemia, insulin deficiency, diminished adrenergic signaling.

The differential diagnosis in this condition will be: –

1. Hyperkalemia of renal failure-due to failure to augment distal tubular potassium secretion and excretion of potassium through renal tubules.

2. Drug-induced hyperkalemia- Use of ACEi/ARBSs or beta-adrenergic blockers for hypertension may cause hyperkalemia due to kidney impairment.

Criteria for beginning hemodialysis were symptomatic lethal hyperkalemia which is resistant to other medical therapy with elevated creatinine levels due to kidney failure and life-threatening cardiac arrhythmia due to hyperkalemia which may lead to cardiac arrest. The acute treatment of life-threatening hyperkalemia necessitates infusion of intravenous calcium to protect against malignant cardiac hyperexcitability followed by agents such as intravenous insulin along with iv dextrose to prevent hypoglycemia to rapidly shift potassium into the intracellular space (Montford, & Linas, 2017). Sodium bicarbonate also may be used in acidosis correction which will correct hyperkalemia and oral agents such as sodium polystyrene sulfate or oral kayexalate to potentiate the GI excretion of potassium may be used. If any of these therapies are not able to bring down the potassium level and patiently continue to have tachy or Brady arrhythmia, an urgent referral to a nephrologist needed for emergent hemodialysis. Since the patient is worried about “being tied to the machine”, I would discuss in detail the need for emergent hemodialysis as a life-saving measure and if recovered, in the future other medical and nutritional management can be adopted. Another form of dialysis such as peritoneal dialysis is done for the non-emergent situation and in chronic stages for patients who are asymptomatic and more controlled lab values who meet the criteria.

Nutritional interventions that I discuss with my patient are avoidance of fruits and fruit juices that contain a high level of potassium and avoid other potassium-rich food supplements in the markets when taking medical therapy for hypertension and renal failure. Avoidance of drugs causing hyperkalemia such as ACEis and ARBs until instructed by the provider. I would refer to a dietician/nutritionist who may be helpful to teach and counsel patients on nutritional restrictions to prevent future incidences. 

Reference.

Montford, J. R., & Linas, S. (2017). How dangerous is hyperkalemia?. Journal of the American society of nephrology, 28(11), 3155-3165. Retrieved from https://jasn.asnjournals.org/content/28/11/3155?utm_source=TrendMD&utm_medium=cpc&utm_campaign=TMDPJ&WT.MC_ID=TMDPJ

Q-3

Do you have any pain or discomfort when urinating? , Are you able to void at all, location of pain, provocation and alleviating factors, type and nature of pain, quality of pain whether is it an acute, chronic, continuous or intermittent and previous incident, and any radiation, intensity or severity, and associated symptoms such as hematuria, anuria, oliguria, passing of stones and spasm, fever, chills, nausea, vomiting, any swelling of body parts. An initial detailed history which includes current prescription and non-prescription medications such as anticholinergics, antiarrhythmics, antidepressants, antihistamines, antihypertensives, antiparkinsonian agents, antipsychotics, hormonal agents and muscle relaxants and Herbal supplements and medical history, sexual history, and previous instrumentation (Serlin, Heidelbaugh, & Stoffel, 2018). Depends on the patient’s acuity of symptoms for not voiding more than 8 hours with severe pain/discomfort with distension of the urinary bladder (lower abdomen), unable to urinate with a full bladder is a bladder outlet obstruction emergency that needs immediate intervention.

The diagnostic tools I would use is a focused physical exam of the abdomen with neurologic evaluation, starting with inspection for bladder distension, palpation of the lower abdomen and pelvis, and percussion. A bladder scanning for post-void residual will determine the volume of urine in the bladder (Serlin, Heidelbaugh, & Stoffel, 2018). Initial management of urinary retention involves assessment of urethral patency with complete bladder decompression by catheterization. If unsuccessful a CT or US of the abdomen, pelvis for any mass or malignancy causing bladder obstruction. An MRI scan may be warranted for lumbosacral spinal causes and other neurological causes and urologist/ and neurology needs to be consulted for management. Other lab tests indicated were PSA antigen to screen for BPH, prostate cancer, acute prostatitis in the setting of acute urinary retention. A serum blood glucose to evaluate uncontrolled diabetes with neurogenic bladder, serum blood urea nitrogen, creatinine, electrolytes to evaluate for renal failure from lower urinary tract obstruction, urine analysis for infection, hematuria, proteinuria, and glucosuria.

Education of patient on environmental and nutritional interventions

Have a bladder graining program instructions such as empty the bladder as soon as the patient gets up in the morning, have a schedule for bladder emptying and void only at the scheduled time during day time even if the urge to go before the time or no urge to go at the scheduled time. Use urge suppression techniques and deep breathing exercises until the sensation passes. Practice pelvic exercises (Kegel’s) to strengthen the bladder muscles. Take 2-3 liters of fluids per day and drink most of it in the daytime and reduce fluid intake towards evening and night hours and empty bladder prior to going to bed.

Reference.

Serlin, D. C., Heidelbaugh, J. J., & Stoffel, J. T. (2018). Urinary retention in adults: evaluation and initial management. American family physician, 98(8), 496-503.Retrieved from 

https://www.aafp.org/afp/2018/1015/p496.html