Question

Use the following case study to develop a plan of care

30 Y.O female presents with an 8 -week history of bloody diarrhea

Abdominal exam: Guarding and tenderness noted in the left iliac fossa and hypogastrium. Pt complains of malaise, lethargy and anorexia. She has lost 8kg in the past 2 months

Vital Signs

BP 122/72

Heart rate 80

Res 18

Temp 37C

Pale mucous membrane

Diagnosis: Ulcerative Colitis

(Develop a plan of care: history, likely symptomatology, detailed pathophysiology, detailed treatment plan)

Answer 1

Plan of care:

Diagnosis: Ulcerative colitis

History: bloody diarrhoea for 8weeks.

Symptoms: guarding and tenderness in left iliac fossa and hypogastrium,malaise, lethargy and anorexia,weight loss.

Pathophysiology:-

Ulcerative colitis is an inflammatory disease of the colon charecterised by bloody diarrhoea.It initially affects rectum and spread to colon. People with ulcerative colitis has an increase in sulphate reducing bacteria in the mucosa and submucosa which produce a toxic gas called hydrogen sulphide.This results in breaking the epithelial mucosal barrier causes inflammation.

Treatment plan:

Treatment plan includes either medication or surgery.Medical management depends on the severity of the disease.

Medication:- 5 amino salicylic acid -eg: Azulfidine.

Corticosteroids,immunomodular drugs,biologics.

Surgery:- proctocolectomy with ileoanal pouch anastomosis.

Dietary management:- limit diary products, limit fibre, avoid spicy, alcohol and caffeine,eat small meals, drink plenty of liquids.