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Diverticular Disease

Diverticular Disease. Edward Via Virginia College of Osteopathic Medicine Department of Geriatrics Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012. History of Present Illness.

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Diverticular Disease

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  1. Diverticular Disease Edward Via Virginia College of Osteopathic Medicine Department of Geriatrics Edward Warren, MD, Chair Geriatrics, Carolinas Campus, February 2012

  2. History of Present Illness 78 year old white female with 2 day history of increasing abdominal pain. Patient states that she has had some bleeding in the past but none recently. Patient denies any recent changes in medications or diet. Patient tried a clear liquid diet for 24 hours and felt somewhat better but over the last day she has been feeling worse. Pain is more intense in the lower abdomen.

  3. Past Medical History • IBS (Irritable Bowel Syndrome) • Depression with anxious features • Migraine headaches • Fibromyalgia • GERD (gastroesophageal reflux disease)

  4. Family History • Crohn’s disease • Migraine headaches • Fibromyalgia

  5. Past Surgical History • Cholecystectomy • Appendectomy • Total hysterectomy with bilateral salpingo-oopherectomy

  6. Social History • She lives in a nursing home • She is a widow with 2 children • She worked as a secretary. • She is a Methodist • No ethanol • No tobacco

  7. Medications • Omeprazole 20 mg - 1 tab po daily • Dicyclomine 20 mg - 1 tab po 4x/day prn abdominal pain • Sertraline 50 mg - 1 tab po daily • Acetaminophen 500 mg - 1 tab po 4x/day prn pain

  8. Allergies • Penicillin

  9. Review of Systems • No nausea or vomiting, no fever, Occasional diarrhea, no hematochezia, • All remaining review is unremarkable

  10. Physical Exam • This is a well developed, slightly dehydrated, white female who is in moderate distress. • Vitals - T 99.9 P 80 regular R 20 regular BP 145/89 • HEENT - unremarkable • Neck - Supple, no JVD, bruit, or lymphadenopathy • Heart - RRR w/o Murmur, no S3, no S4 • Lungs - clear to auscultation and percussion w/o rales or rhonchi • Abdomen - Soft, tender in left lower abdomen, BS decreased but present in all quadrants, no rebound tenderness, no rigidity, no mass, and no organomegaly

  11. Question1 After evaluation of this patient you suspect that she has uncomplicated diverticulitis. While you are waiting for the CBC results as well as an abdominal x-ray you decide to start her on antibiotics. What would be an appropriate initial antibiotic to start her on? • Amoxicillin/clavulanic acid with metronidazole • Trimethoprim/sulfamethoxazole • Penicillin • Ciprofloxacin with metronidazole • Ciprofloxacin

  12. Question 2 Which of these recommendations have been shown to be of benefit for patients with diverticular disease? • Routine exercise • High fiber diet • Low fat diet • Obesity has been shown to be associated with increased diverticulosis • Discontinuing smoking

  13. Question 3 Her abdominal x-ray and CBC are all within normal and you feel confident that she has a simple case of uncomplicated diverticulitis. The next day she returns to your office stating that she has been vomiting and that her abdomen hurts worse. On exam she has diffuse tenderness of the entire abdomen with slight rebound pain present. With the above findings you • Change her antibiotic to a different oral medication • Give her another 24 hours to let the antibiotic take effect • Schedule her an appointment to see a surgeon • Schedule her for a CT scan within the next 1-2 days • Admit her to the hospital for IV antibiotic and possible surgical intervention

  14. Question 4 • Which of the following would increase the risk of complications in a patient with diverticulitis? • Long term steroids • Lupus erythematosis • Diabetes mellitis • Renal failure • All of the above

  15. Question 5 5.The most common area of the abdomen for patients to feel pain initially is in the a. Right upper quadrant b. Right lower quadrant c. Left upper quadrant d. Left lower quadrant e. Mid epigastrum

  16. Answers • Ciprofloxacin with metronidazole, “d”, is the answer. They cover gram negative organisms and anaerobic orgnisms respectively. The other choices fall short of this standard. • High fiber diet, “b” is the answer. • Admit her to the hospital for IV antibiotic and possible surgical intervention, “e” is the correct answer. • All of the above, “e” is the correct choice due to adverse effects of these conditions on the immune system. • Left lower quadrant, “d” is the answer due to the smaller lumen and higher pressures.

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