ulcerative colitis case presentation

A chronic, inflammatory bowel disease that causes inflammation in the digestive tract.
Ulcerative colitis is usually only in the innermost lining of the large intestine (colon) and rectum. Forms range from mild to severe.

1. ULCERATIVE COLITIS ANSHU REDDY 21EF1T0019 CASE PRESENTATION

2. Demographic details : Name : xyz age and sex : 15 f IP number : 057558 Ward : general ward Chief complaints : c/o severe lower abdominal pain and c/o loose stools with generalized weakness

3. History of present illness Patient was apparently assymptomatic 2 days back then developed severe abdominal pain associated with frequent small loose stools and generalized weakness History of past illness No history of DM 2 CVA CAD HTN EPILEPSY

4. personal history Diet : mixed bowel and bladder : Normal Sleep : adequate Addictions : no G/E Pt c/c/c Temp : afebrile BP : 100/70 mmhg PR : 96bpm CVS : s1 s2+ LUNGS : clear P/A : soft

5. PROVISIONAL DIAGNOSIS ? Stomach infection INVESTIGATIONS ECG,CBP,CUE,USG,CT Scan,Colonoscopy , Sr electrolytes,Sr creatinine, C reactive protein

6. ULCERATIVE COLITIS FINAL DIAGNOSIS :

7. SOAP notes

8. Female patient of 15 years was presented with above mentioned complaints and got admitted under the care of gastroenterologist. SUBJECTIVE

9. OBJECTIVE All the above investigation work done ECG : normal CBP : Test description result 3/11 5/11 7/11 8/11 Reference Haemoglobin 12.2gms 11.8gms 11.2gms 11.1gms 12.5 to 16.0 RBC 3.6millions/ microlitre 3.4 3.3 3.2 4.2 to 5.4

10. Test description Result 3/11 7/11 8/11 Reference Sr creatinine 0.6 0.5 0.5 0.6 to 1.1 C reactive protein 39.7 39.7 38.1 0 to 0.60 Impression : High CRP is more than 10mg/L. This shows that there is inflammation somewhere in your body Serum electrolytes : normal

11. USG Both ovaries increased in volume showing multiple immature follicles and Central echogenic stroma. focal wall thickening involving caecum and adjacent inflamed fat planes Impression : TYPHILITIS changes Features of pcod consult gynaec Ct scan of abdomen Impression : Irregular circumferential wall thickening at caecum ascending colon transverse colon descending colon sigmoid colon and rectum

12. USG Severe ulceration with exudation from rectum up to mid transverse colon Impression : Ulcerative colitis

13. ASSESSMENT Based on subjective and objective references the patient was assessed with ulcerative colitis

14. PLAN Goals of treatment :- To decrease the pain and frequent motions To avoid future recurrence To improve the quality of life

15. PHARMACOLOGICAL TREATMENT drug Brand name Dose and frequency Injection magnex forte Sulfbactam and cefoperazone 1.5gm/ i.v /12 th hrly Injection buscogast Hyoscine butylbromide 1amp/ i.v /8 th hrly Injection metrogyl Metronidazole 500mg/ i.v /8 th hrly Injection tremezee tramadol 20mg / i.v /s o s Fluids DNS n RL Dextrose NaCl and ringers lactate 100ml / hr Injection razo rabeprazole 20mg/ i.v 12 th hrly ani transdermal patches are also used

16. PATIENT COUNCELLING About drugs : - Inj tremezee : Tramzee Injection is a painkiller medicine used to relieve severe persistent pain.inhibits the production of chemical which is responsible for pain (prostaglandins) Side effects :- Injection site reactions Drowsiness Headache Dizziness Nausea Vomiting Constipation

17. INJECTION RAZO Gastroesophageal reflux disease (Acid reflux) Treatment of Peptic ulcer disease Razo IV Injection is a proton pump inhibitor (PPI). It works by reducing the amount of acid in the stomach which helps in relief of acid related indigestion and heartburn. Long-term use of Razo IV Injection can cause weak bones and a deficiency of minerals such as magnesium. Take adequate dietary intake of calcium and magnesium or their supplements as prescribed INJECTION METROGYL Used for various bacterial infections such as peritonitis (inflammation of abdominal lining), intra-abdominal abscess (pus in abdomen), and liver abscess. Metronidazole diffuses into the organism, inhibits protein synthesis by interacting with DNA, and causes a loss of helical DNA structure and strand breakage. Nausea, vomiting, metallic taste, abdominal cramps, eating disorders are a few common side effects

18. Magnex Forte Injection :- This medicine works by preventing the formation of the bacterial cell wall which is important for the growth of bacteria. Magnex Forte 1.5 g Injection shows side effects like nausea, vomiting, diarrhoea , anaemia (low number of red blood cells), etc. Buscogast 20mg Injectio n used in the treatment of pain due to smooth muscle spasm. It relieves cramps in the stomach, intestine, bladder, and ureter. Side effects like dry mouth, blurred vision and irregular heartbeat Exerts a spasmolytic action on the smooth muscle of the gastro-intestinal, biliary and genito -urinary tracts.

19. Patient responding well continued same treatment and advised discharge with followup medical advise. Patient is stable symptomatically and haemodynamically at the time of discharge. DISCHARGE ADVICE 1.CAP. RABLET – D ONCE DAILY AT 7AM BEFORE BREAKFAST X 5 DAYS

2.TAB. OFLOX – OZ TWICE DAILY AT 8AM-8PM X 5 DAYS

3.TAB. MEFTAL SPAS TWICE DAILY AT 8AM-8PM X 5 DAYS

20. Cap. Rablet D Antacid ( Rabeprazole sodium 20mg & Domperidone ] 30mg side effects: - flatulence, Diarrhea, Dryoness in mouth Tab. Oflox-02 Ofloxacin 200mg nd Ornidazole 500mg – Antibiotic sideffects :- Nausea, Dizziness, Vomitting Meftal spas500mg Mefenamic acid – Analgesic sideffects :- Vomitting , Headache, Dizziness

21. PATIENT COUNSELING LIFE STYLE MODIFICATIONS Avoid all spicy foods Well cooked vegetable or fruits need to be taken Regular timings should be maintained Avoid eating raw vegetables Tea coffee processed foods are avoided Skimmed milk can be taken