My routine, when entering exam rooms, has remained the same since I was a student:
1. Walk in
2. Introduce myself
3. Lather up some liquid soap between my hands for hygiene
4. Quickly answer a single question in my mind: “Is this patient sick or not sick?”
The above question is important to keep in mind, regardless of specialty or setting, because inevitably, there will always be the rare patient who needs a higher level of care urgently or even emergently.
Answering the above question obviously becomes paramount.
I can still recall the first time my answer to the above question was wrong – it was a warm morning and I was half way through my family medicine rotation.
A 78 year old male came into the clinic complaining of a persistent aching left lower quadrant pain.
His past medical history was fairly unremarkable. He didn’t have a fever. He wasn’t tachycardic. His wife “wasn’t going to bring him in”.
As the student, I was given the privilege of taking his history and performing an examination. His abdomen was tender, but mostly unimpressive. I had seen acute abdomens during my surgical rotation and he certainly didn’t have one. No guarding. No rebound.
All in all, I thought he looked well. Certainly not sick.
When I presented to my preceptor, I reviewed the above and started in on my treatment plan.
My differential included musculoskeletal pain, constipation, irritable bowel syndrome, and everyone’s favorite, “viral gastroenteritis”. Although the more concerning causes of abdominal pain were in the back of my mind, they didn’t seem to jump out.
I suggested supportive care at home and re-evaluation if pain worsened or new symptoms arose.
When we entered the room, I was fairly confident in myself. As the patient started to repeat the history, I felt things start to unravel.
We’ve all been there as students, experiencing the seemingly impossible change in symptoms, in the 10 minutes between you taking the history and your preceptor’s history.
A separate article could be written entirely on patients answering questions differently to students versus their preceptors, but hey, not the scope of today’s article!
After the history, my preceptor examined the patient and to my relief, agreed that his abdomen was mostly non-tender.
I started to think maybe the case could be won. As my preceptor started to explain his plan, he elaborated on one important point. The difference, between my history and his, was that he’d known the patient for many years, and was able to pick up subtle clues that I had not.
First off, he said, the patient himself did not complain much. Therefore, the fact he came in to seek care, increased his suspicion that something more serious could potentially be occurring.
Additionally, when he did come in for his routine follow ups, he was always dressed professionally and tidy. Today, our patient was in unkempt sweat pants, and looked like he had just gotten off the couch.
Both these things, along with the clinician’s gestalt of “something just isn’t right”, motivated my preceptor to pursue a diagnosis of acute diverticulitis. This was ultimately confirmed, via CT scan, and was treated in the outpatient setting with oral antibiotics.
Although the deck seemed as if it was stacked against me, because I did not have the same relationship with the patient, I could not help but feel rattled. I had swung and missed.
Had I sent the patient home, he may have been delayed valuable time to treatment.
Being a student, it was great to have a preceptor to help guide our treatment plan, however I could not help but be concerned, as graduation and becoming a practicing PA were looming.
After that patient, I resolved to get more serious about my internal questioning when seeing patients. Not only did I continue to ask myself whether the patient was sick, but I started to look differently at the entire picture.
Taking into account the subtle clues that patients tell us can help us make valuable decisions. Always commenting on appearance, clinical history, and surrounding details can be helpful.
As Sir William Osler said, “Listen to your patient, he is telling you the diagnosis”.
What is Diverticulitis?
Diverticulitis is an inflammation and outpouching of the colonic mucosa; this is a very common disease. Its precursor, diverticulosis, is even more common and generally asymptomatic.
Many patients have asymptomatic diverticula, which can in turn become inflamed with fecal material, cause edema, and if untreated, perforation can occur. The pathophysiology includes a decreased luminal pressure in the intestine which can result in outpouchings and inflammation.
Risk Factors for Diverticulitis
Risk factors for diverticulitis include:
– Age greater than 40
– Chronic low fiber diet
– Western lifestyle
Prevention of diverticulitis can be accomplished with regular exercise, having regular, well-formed bowel movements, following a vegetarian diet, and eating more than 30 grams of fiber per day.
Patients with diverticulitis can be sub-divided into categories. As stated previously, about 80% of those with diverticulosis are asymptomatic. Of the patients who progress to diverticulitis, about 75% are uncomplicated while 25% are complicated.
Complicated patients may need admission to the hospital for treatment, while uncomplicated patients may be treated in the outpatient setting.
Patients presenting with diverticulitis may complain of a persistent aching in the left lower quadrant of the abdomen. Initially, pain may be minimal, but can progress to florid rebound tenderness with guarding.
Patients may also have fever, chills, nausea, vomiting, or urinary symptoms if there is bladder irritation involved. Painless rectal bleeding and/or diarrhea should clue a clinician in to diverticulitis.
On exam, patients may be tender in the left lower quadrant. If the disease has progressed, peritoneal signs, such as guarding and rebound tenderness can be present.
Bowel sounds should always be assessed. The abdomen may be distended. A rectal exam may be tender. Signs of sepsis, including fever, tachycardia or hypotension should warrant immediate action.
Working Up The Patient with Diverticulitis
Work up related to diverticulitis should depend on the acuity of the patient.
In the outpatient setting, patients may not need lab work. Personally, I almost always order imaging to confirm the diagnosis.
Some clinicians will argue, if a patient has routine episodes (who has had previous diverticulitis), that imaging is not necessary. An early CBC may be normal. A later CBC may show leukocytosis with left shift. Inflammatory markers such as CRP/ESR can help confirm the diagnosis. A urinalysis may show microscopic hematuria or pyuria.
An abdominal flat plate x-ray can show air under the diaphragm or evidence of bowel obstruction. Ultrasound can be efficient to diagnosis diverticulitis, but may be technically difficult in an obese patient.
The CT scan with contrast is the gold standard for diagnosing diverticulitis and can help determine medical versus surgical management. Endoscopy can be used to rule out upper GI bleeding.
As discussed above, treatment and management of this condition depends on the patient. It is important to note that diverticulosis is encountered commonly on outpatient colonoscopy.
Treatment includes regular exercise, hydration, fiber supplements, bulking agents to reduce constipation. Patients should be encouraged to consume at least 30 to 50 grams of fiber per day.
Patients with uncomplicated diverticulitis may be managed with oral antibiotics. These patients should not have any signs of systemic toxicity and should be educated on the signs and symptoms that would warrant re-evaluation.
A first line combination therapy, includes ciprofloxacin 500 mg twice per day and metronidazole 500 mg three times per day.
Second line treatment, due to allergy or intolerant to the above includes, Augmentin 875-125 twice per day for ten days.
Patients who do not qualify for outpatient management may need parenteral antibiotics in the hospital. These include broad spectrum antibiotics such as piperacillin-tazobactam.
Bowel rest can be encouraged. A high fiber diet is not recommended during an acute flare up of diverticulitis. Opioid medicines should be avoided as they may contribute to ileus or delay gastrointestinal transit.
Unfortunately, for some patients, the management of diverticulitis with abscess or perforation is surgical. Patients with peritoneal signs of hemodynamic instability may need emergent surgical management of their condition.
The risk of recurrence increases with subsequent episodes. Younger patients tend to have more recurrences. Prompt diagnosis and treatment remains the cornerstone of successful management.
Hardy, D.M and Holsten, S.B (2016). Diverticular Disease. The Five Minute Clinical Consult.