Biophysical Processes And Health Assessment: Understanding Mr. A’s Health Condition

Health History Assessment

Discuss about the Biophysical Processess and Health Assessment.

Mr. A (70 yrs) is from the Srilanka. He is living alone in his home on the outskirt of city alone as his wife was expired two years before. He is not interested to stay with his son who is staying in the same city. His is financially weak as he don’t have any income source and he is having very little pension. Hence, he can’t offer to have helper to assist in his activities of daily living. Community from which Mr. A belongs is traditionalist in character, as people from this community are not interested to share their health problems with healthcare professional. 15 years before he was diagnosed with peptic ulcer, diabetes, obesity, ostoporosis, fatty liver cirrhosis and hypertension and till date he is having these disease conditions. Mr. A was consuming bisoprolol, atenolol, esomeprazole, metformin, frusemide, spironolactone and orlistat since some time. He was on alcohol consumption and chronic smoking since few years. Milk products and eggs are allergic to him. He is not eating nutritious food and as result his nutritional balance is impaired.

In recent times, his vital systems were tested and below are the observations.

He has breathing problem, stomach pain, vomiting, insomnia and he has feeling of loss of appetite and lethargy. It is evident that he wishes to keep isolated from society and family members and completely depressed. Mr. A feels that society and family members are not going to accept him in this condition. Society and family members are unhappy with his lifestyle since long time and his presenting condition is due to his lifestyle. As he is depressed, he is forgetting routine things and he disoriented to time, however he is oriented to the people.

Liver function tests are performed for Mr. A because he has liver cirrhosis. Liver function test generally estimates proteins such as alanine transaminase (ALT), aspartate aminotransferase (AST), albumin, and bilirubin. Atypical level of these proteins exhibit degree of liver damage or scarring. Full blood examination (FBE) exhibit complete examination of health of the Mr.A. Diagnosis of acute inflammation can be performed by C-reactive protein (CRP) estimation. Test for the inflammation was performed because Mr. A has peripheral oedema (cirrhosis).  MBI test is generally performed as metabolic panel test essentially for diabetes, liver disease, kidney disease and hypertension. MBI test was performed because Mr. A is having multiple diseases.  CT scan of the left hip of Mr. A was performed as Mr. A has pain in hip. With the help of CT scan degree of compression of fracture can be determined and it is also useful for the evaluation of severity of osteoporosis. X-ray of spine pelvis right hip was carried out in the patient for the assessment of  dislocation of three bones of the pelvis like illiun, ischium and pubis (Fischbach and Barnett, 2009; Novelline and Squire, 2004).

Physical Examination

Mr. A has cardiovascular complications since some time and he taking medicines for the same. To assess his current cardiovascular complications his blood pressure should be assessed. He is also having breathing problem and to assess his current lung function pulmonary function test should be performed. He is also having liver cirrhosis, hence his liver function test should be performed. In these evaluations it has been observed that his cardiovascular system, respiratory system and liver are normal (Jensen, 2010).

Head, ears, eyes, nose and throat (HEENT) Observations  :

Head : No headache, giddiness

Ears : No problem in hearing .

Eyes : No problem in vision, No blurred vision and there are no spots in the eye.

Nose : No assessment.

Throat : Swelling in the throat.

Cardiovascular: Occasional mild chest pain, occasional very little palpitations.

Pulmonary : No shortness of breath and no cough.

Gastointestinal : There is epigastric pain since long time, diarrhea and bloody stools and loss of appetitie.

Genitourinary : No urgency in urination

Neurologic : No numbness, tingling and paresthesias.

Mukosleletal : Abdominal pain after lifting little heavy bag.

Endocrine : No assessment.

Physical examination:

Vital signs  : B.P. – Systolic 120 mmHg and diastolic 80 mmHg, Blood sugar level – 110 mg/dl, Body weight – 75 kg, Live function test – AST – 70 IU, ALT –  50 IU

Forced expiratory volume (FEV1) – 75 %

Conclusion : From the above physical examination and vital signs and other tests, it is evident that disease of Mr. A like hypertension, diabetes, cirrhosis are in control now. However from symptoms like stomach pain, bloody diarrhea and loss of appetite is predicted that he is suffering from Inflammatory bowel disease and decided to go for diffential diagnosis of inflammatory bowel disease.

Possible diffential diagnosis : Crohn’s disease and ulcerative colitis.

Crohn’s disease and ulcerative colitis are types of inflammatory bowel disease. Crohn’s disease and ulcerative colitis are the inflammatory disease of the GI tract and these two disease share few common factors like symptoms. Also, these two disease share common etiological factors like environmental, genetic and an abnormal immune response. These two diseases can occur equally in men and women. Crohn’s disease is spread intermittently in the large and small intestines with few areas are inflamed and few areas are normal. Ulcerative colitis can be continuous inflammation particularly in the small intestine. . Crohn’s disease occurs throughout every layer of the intestinal wall, on the other side ulcerative colitis occur particularly in the inner lining of the colon (Targan et al., 2013; Cohen, 2005).

Investigation

Conclusion:   Out of total cases of inflammatory bowel disease around 10 % cases exhibit characteristics of both Crohn’s disease and ulcerative colitis and moreover severity and occurrence of these diseases is similar in all age groups. This together occurrence of Crohn’s disease and ulcerative colitis is called as intermittent colitis. Out of these two diseases, one particular disease is not age related and both disease occur at any stage of life. Hence, in few cases it is very difficult to differentiate between these two diseases. Nevertheless, a careful medical history, physical examination, use of screening tools, and correct diagnostic tests can precisely differentiate between these two inflammatory bowel disease conditions in most patients, allowing disease-specific management (Tontini et al., 2015).  

Physical examination:

Physical examination of the patient should be performed along with asking questions to the patient. There is the possibility of fever due to intestinal inflammation and dehydration due to diarrhea. Hence, temperature should be noted and about dehydration Mr. A should be asked about his fatigue and lethargy. This fatigue and lethargy also would be helpful in evaluating anemia because bloody diarrhea, there is the possibility of anemia in Mr.A.

There is also possibility of weight loss in patients with inflammatory bowel disease. Hence,  weight of Mr. A, also should be noted.     

Stomach pain in particular area should be evaluated by slight pressing of the stomach area and inquiring Mr. A about the pain sensation.

Inflammatory bowel disease is generally associated with extra intestinal complications like arthritis, iritis and dermatitis. These complications also should be evaluated by observation of the particular part and asking Mr. A about any abnormal feeling in that part like pain in limb in arthritis.  

Rectal examination should be performed to assess bloody stool because in inflammatory bowel disease, there is occurrence of bloody diarrhea (Targan et al., 2013; Cohen, 2005).

Biomarker analysis: As IBD is inflammatory bowel disease further prediction of Crohn’s disease and ulcerative colitis can be performed by inflammatory biomarker analysis like CRP, IL-6, INF gamma and IL-13. Immunologically Crohn’s disease is TH1 mediated inflammatory disease INF gamma predict about the occurrence of  Crohn’s disease. On the other side, ulcerative colitis is TH2 medicated disease, IL13 predict about ulcerative colitis. Even tough, CRP doesn’t give clear differentiation between Crohn’s disease and ulcerative colitis, it has been found that CRP levels are slightly higher in Crohn’s disease than ulcerative colitis. Serum IL6 levels are also slightly higher in Crohn’s disease than ulcerative colitis. Serum biomarker as diagnostic test should be performed initially because it is simple test and it give good prediction without much complication to the patient. From biomarker analysis, it is evident that Mr. A has ulcerative colitis (Lewis, 2011; Iskandar et al., 2012).

Cross-sectional imaging:       

Cross-sectional imaging can be helpful in the identification of the stage of the inflammatory bowel disease. This includes tools like ultrasonography, computed tomography, magnetic resonance imaging and barium contrast radiology. Decision on the selction of the tool for cross-sectional imaging depends on the patient condition, severity of the symptoms in the patient, availability of expertise and instrument. Along with the identification of  location of the lession, cross-sectional imaging is also helpful in the evaluation of the thickness of the colonic wall and examination of the different layers of the colonic wall. This analysis of each wall of the colonic wall helps in the differential diagnosis of Crohn’s disease and ulcerative colitis because Crohn’s disease occurs throughout all the layers of colonic wall and ulcerative colitis occurs in the inner layer of the colonic wall. These imaging techniques also helpful in the assessment of presence or absence of colonic lymph nodes From cross sectional imaging, it is evident that Mr. has ulcerative colitis (Braveman et al., 2004; Tekkis et al., 2005).   

Ileo-colonoscopy : Ileo-colonoscopy helpful in the differential diagnosis in the inflammatory bowel disease because in this examination patient with Crohn’s disease exhibits discontinuous inflammation of colonic wall, lesions and cobblestoning of the mucosa. On the other side, ulcerative colitis exhibits erosions,continuous inflammation, microulcers and granularity in the mucosa. From Ileo-colonoscopy it is evident that Mr. A has ulcerative colitis (Dignass et al., 2012).   

Histopathology : For the differential diagnosis of the inflammatory bowel disease, histopathology was performed from the two specimens from the five sites of the colon of the colon, rectum and terminal ileum. In histopatological analysis, Crohn’s disease exhibits architectural and inflammatory changes which depicts discontinuous alterations throughout the colon, focal cryptitis, inflammation of the lamina propria and mucin deposition. Ulceratice colitis exhibits paneth cell metaplasiain the distal part of the colon, depletion of mucin, inflammatory cell infiltration throughout the mucosa, distorted crypts and surface erosions. From histopathological analysis it is evident that Mr. A has ulcerative colitis (Magro et al., 2013).

Upper endoscopy: Esophagogastroduodenoscopy is helpful in the patients with suspected Crohn’s disease because this particular disease of the inflammatory bowel disease is related to the upper gastrointestinal tract. This diagnostic tool is not valid exclusivity for Crohn’s disease because upper endoscopy is also useful for the diagnosis of the Helicobacter pylori infection, sarcoidosis, tuberculosis and gastric adenocarcinoma. This diagnostic test was rejected in Mr. A because other above performed tests clerly indicated occurrence of ulcerative colitis in Mr. A (Annese et al., 2013).

Small-bowel endoscopy:  Small-bowel endoscopy is also specifically useful for the examination of the upper gastrointestinal tract. Hnece, this test was also not considered for the diffential diagnosis of Mr. A, because in other diagnostic tests it was confirmed that Mr. A has ulcerative colitis (Flamant et al., 2013).

Conclusion:

In the health assessment of Mr. A, stepwise approach was followed starting from the collection of the history of Mr. A in terms of family history and medical history. In this it was identified that Mr. A has very unhealthy lifestyle which was responsible for the multiple disease in M. A like cardiovascular disease, diabetes, obesity, liver disease and his condition was like a patient with metabolic syndrome. As, he was consuming medications for these conditions, his most of the health issues in the past are in control now. It is evident from the tests performed for diabetes, blood pressure and liver function test. Recently he was suffering from the intense stomach pain and bloody diarrhea. Hence, it was predicted that Mr. was suffering from inflammatory bowel disease. Inflammatory bowel disease comprised of Crohn’s disease and ulcerative colitis, specific diagnosis was performed for Mr. A by applying differential diagnosis. In the diffential diagnosis it is evident that Mr.A is suffering from the ulcerative colitis.

References:

Annese, V., Daperno, M., Rutter, M.D., Amiot, A., Bossuyt, P., & East, J. (2013). European evidence based consensus for endoscopy in inflammatory bowel disease. Journal of Crohn’s and Colitis, 7(12), 982-1018.

Braveman, J.M., Schoetz, D.J., Marcello, P.W., Roberts, P.L., et al. (2004). The fate of the ileal pouch in patients developing Crohn’s disease. Diseases of the Colon & Rectum, 47, 1613–1619.

Cohen, R. D. (2003). Inflammatory Bowel Disease: Diagnosis and Therapeutics. Springer Science & Business Media.

Dignass, A., Eliakim, R., Magro, F., Maaser, C., Chowers, Y., et al. (2012). Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 1: definitions and diagnosis. Journal of Crohn’s and Colitis, 6, 965–990.

Fischbach, F.T., & Barnett, M. (2009). A Manual of Laboratory and Diagnostic Tests. (8^th ed.). Lippincott Williams & Wilkins.

Flamant, M., Trang, C., Maillard, O., Sacher-Huvelin, S., Le Rhun, M., Galmiche, J.P., & Bourreille, A. (2013). The prevalence and outcome of jejunal lesions visualized by small bowel capsule endoscopy in Crohn’s disease. Inflammatory Bowel Disease, 19(7), 1390-6.

Iskandar, H.N., & Ciorba, M.A. (2012). Biomarkers in inflammatory bowel disease: current practices and recent advances. Translational Research, 159, 313–325.

Jensen, S. (2010). Pocket Guide for Nursing Health Assessment: A Best Practice Approach. Lippincott Williams & Wilkins.

Lewis, J, D. (2011). The utility of biomarkers in the diagnosis and therapy of inflammatory bowel disease. Gastroenterology, 140:1817–1826.e2.

Magro, F., Langner, C., Driessen, A., Ensari, A., Geboes, K., et al. (2013). European consensus on the histopathology of inflammatory bowel disease. Journal of Crohn’s and Colitis, 7(10), 827-51.

Novelline, R. A., & Squire, L. F. (2004). Squire’s Fundamentals of Radiology. (6^th ed.). Harvard University Press.    

Targan, S.R., Shanahan, F. Karp, LC. (2007). Inflammatory Bowel Disease: From Bench to Bedside. Springer Science & Business Media.

Tekkis, P.P, Heriot, A.G., Smith, O., Smith, J.J., Windsor, A.C., & Nicholls, R.J. (2007). Long-term outcomes of restorative proctocolectomy for Crohn’s disease and indeterminate colitis. Colorectal Disease, 7, 218–223.

Tontini, G.E., Vecchi, M., Pastorelli, L., Neurath, M.F., & Neumann, H. (2015). Differential diagnosis in inflammatory bowel disease colitis: state of the art and future perspectives. World Journal of Gastroenterology, 21(1), 21-46.