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Clinical Case Study Project

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chris herrera

on 22 January 2014

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Transcript of Clinical Case Study Project

Clinical Case Study
Clinical Case Study on Diverticulitis

By: Chris Herrera

Diverticulosis & Diverticulitis
A condition where sac-like herniations are present throughout the colonic wall.
Saclike herniations are described as Diverticula, an outpouching of the wall of the gut to form a sac.

Typical Complications
Fistula
Mr. FB
History of Present Illness:
Diverticulosis
Diverticulitits
Past Medical History
Past Medical Hx
Ecografia
TAC
Colon por enema
Diverticulitis
Diverticulosis
Medical Treatment
Nutrition Assessment
Nutrition Assessment
Medical Treatment
Medical Nutrition Therapy
Nutrition Therapy
Nutrition History
Patient Education
Patient Education
Endometriosis
Ciclos de la Menstruación
Tumores
Endometriosicos

Sangrado
Clínica
Dolor abdominal a repetición
Dispareunia
Disuria
Defecación Dolorosa
Hipersensibilidad suprapubica
Infertilidad
Inflamación
Tejidos Cicatrízales
Necrosis
Diverticula, Diverticulosis, Diverticulitis and Diverticular Disease; What's the Difference?
-Incidence increases with age
-Sigmoid involvement usually prevalent
-Diverticulosis typically continues unnoticed because its symptons are asymptomatic.
-No indications of infection, perforation, or inflammation
Diverticulosis is diagnosed as diverticulitis when symptons such as inflammation, abscess formation, acute perforation, acute bleeding, or obstruction occur.
Diverticular disease is a term used to describe both diverticulosis and diverticulitis.
Abnormal passage between two organs or between an organ and the skin.
Typically caused by developmental error, trauma, surgery, or inflammatory or malignant disease.
Typical complication of diverticulitis
Colovesical Fistula
Colocutaneous Fisutla
Patient's Initials: FB
Sex: Male
Patient from Sycamore Medical Center

Primary reason patient was chosen for study: Patient previousl and currently has numerous acute and chronic conditions which will enable intern to familiarize with various medical conditions.
Mr. FB underwent a Hartman procedure for perforated sigmoid diverticulitis with sigmoid colon obstruction. He underwent a closure of the colostomy several months after the initial procedure. Their was a reversal of his colon.
Primary Problem and Other Medical Conditions
Mr. FB is 65 year old male who presented with drainage from his anterior abdominal wall midline incision. Also has stool in his urine. Once CT scan was performed, this showed a colocutaneous fistula from the colorectal anastamosis out through the anterior abdominal wall incision. There was also a colocutaneous fistula into the dome of the urinary bladder indicating a colovesical fistula .
Congestive heart failure
Hypertension
Hx of NSTEMI
Hyperlipidemia
Coronary artery disease
Diverticulitits with perforation/abscess s/p sigmoid resection with colostomy
hx of aspiration pneumonia
chronic leukocytosis
anemia
Past Medical History
Scrotal abscess
ETOH abuse
Mumps
Chronic Constipation
Chicken pox
Anxiety
Depression
Edema
Prostate cancer
Pneumonia
Colovesical Fistula
A colovesical fistula is a presence of a communication between the lumen of the colon and that of the bladder
Colocutaneous Fistula
A Colocutaneous Fistula is a presence of communciation between the colon to the anterior abdominal wall
Root cause of diverticulosis is not clearly determined.
It has been considered that colonic structure, motility, genetics, and lifelong low-fiber intake results in increased intracolonic pressure.
Conservative treatment was initiated, was placed on NPO and TPN. This prevented any further drainage. Rationale for this was to allow the GI to rest, slow drainage and allow fistulas to heal.
Fibrin Glue Injection was also done for the fistulous tract
Stool in the bladder
Medical Treatment
Conservative treatment failed after review of a subsequent CT scan and further surgical intervention was needed.
Prior to current diagnosis, Mr. FB underwent a Hartmann procedure for perforated sigmoid diverticulitis with sigmoid colon obstruction.
Hartmann procedure invloves removal of a part of the large intestine. Typically used to treat colon cancer or diverticulitis. Reversal of hartmann procedure after several months.
Medical Treatment
A diverting end transverse colostomy and distal mucous fistula was created.
Nutrition Assessment
TPN Recommendations: Recommend TPN of aa 5%,
d 20%, with 100ml 20% lipids at 70ml per hour.

This will provide 1678 calories and 84g protein
29cal/kg and 1.5g pro/kg

Height: 5'3'' Weight: 126lb( 57kg) BMI: 22 IBW: 52kg % of IBW:109%

Nutritional needs based on actual body weight: (Based on ABW of 57.2kg)

28-30calories per kg= 1600-1715 calories
1.4-1.6g protein= 80-92 grams protien



Nutrition Assessment
Nutrition Diagnosis: Pt with increased protein and calorie needs related wound healing evidenced by colocutaneous fistula and colovesical fistula with scheduled surgical intervention

Nutrition Intervention: Recommend TPN

Nutrition Goals: TPN to meet 100% of nutritional needs within 1-2 days


Patient's physical and psychological response to diet
11/14/13
11/15/13
2013
2010
8/19/13
3/20/2013
Hartmann procedure for
perforated sigmoid diverticulitis
with sigmoid colon obstruction
Closure of
his Colostomy
Admitted to Sycamore hospital
for drainage from abdominal wall
Creation of diverting colostomy and
mucous fistula created.
Patient's Education
Diet high in fiber; 25-35g/day is desirable.
Increase fiber gradually; avoid excess fiber that might interfere mineral absorption
Adequate fluid intake



Follow USDA recommendations, 2-4 servings of fruit, 3-5 servings of vegetables, and 6-11 servings of cereal and grain foods each day.
Eat raw vegetables as much as possible since cooking them may reduce fiber content
Eating the peel of fruits since much of the fiber is found in the skin


Eating fresh and dried fruits
Selecting high in fiber foods by reading labels
Diverticulosis
Recent research had shown that nations who adopt the Western Diet has experienced an increase prevalence of diverticulosis.

Barriers for adequate nutrition: None
Clinical Status: None
Wounds: Colocutaneous fistula and colovesical fistula
Food Allergies: None
Current Diet Order: NPO
Oral Intake: Not applicable
Appetite: Poor

General Information: Patient scheduled for surgery today for diverting colostomy due to colocutaneous and colovesical fistulas per MD notes. Pt was previously on a full liquid diet with poor to fair PO intake prior to NPO status for surgery at LTAC hospital.
Nutrition Risk/Level of Care: High 3
1 meal a day, no breakfast
Does not cosnume fruits and vegetables
Has never been on a diet regimen
Eats out several times a week( Choice of preference Mcdonalds & Burger King)
Coosk his own meals at home
Does not get food from his local grocery
Drinks alcohol( 2-3 whisky shots a day, family reports more)
Consumes Coffee
Choice of beverage mountain dew and pepsi
Patient tolerated TPN
Unsatisfied with the Clear and full liquid diet
After several days, diet was changed to regular and patient seemed more content.
Medications
Metronidazole- eliminates bacteria and other microorganisms that cause infections of the reporodcutive system, GI tract, skin, and other areas of the body.

Vancomycin- used to trat colitits(inflammation of the intestine caused by bacteria) that may occur after the antibiotic treatment. Kills bacteria in the intestines.
Probiotics
Prognosis
Diverticulitis will recur in 20% to 30% patients. Those who aren't treated with surgery have a roughly a 1/3 chance of having a recurrent episode. Recurence may be prevented in more than 70% of those who follow a high fiber diet.
The End
11/16/13
Start of my case study amy initial
assessment with patient
Discharge Date
Timeline
11/27/13
Full transcript