Question

Group Handout Case Study

Inflammatory Bowel Disease

Patient Profile

M.K. is a 22-year-old male who comes to the health care provider for complaints of frequent diarrhea and abdominal pain. He had appendicitis with appendectomy at age 9. He currently takes no medications.

Subjective Data

• Frequently has abdominal pain and diarrhea

Objective Data

Physical Examination:

• Temperature 99.9° F, pulse 78, respirations 16, blood pressure 114/62
• Height 5’3”, weight 100 lb, BMI 17.7 kg/m2

Diagnostic Studies

Lab values:

• WBC: 11,600/µL
• RBC: 3.4 million/µL
• Hematocrit: 33%
• Hemoglobin: 10 g/dL
• Platelets: 190,000/µL
• ESR: 34 mm/hr
• Sodium: 132 mEq/L
• Potassium: 3.2 mEq/L
• HCO3: 25.4 mEq/L
• Chloride: 99.5 Eq/L
• Fecal occult blood tests negative

1.The student will write his or her patient report and share it with the nurse coming in. Please very descriptive.

Answer 1

Twenty two year old young man whose name is MK presented with complaints of frequent diarrhoea and abdominal pain, for last few days, which is associated with fever.He also give a history of appendicectomy at the age of 9. His personal and family history is uneventful. He is adequately immunized for his age.

On physical examination his body temperature was 99.9°F, and his height is 5'3" and weight is 100lb, his BMI is 17.7kg/m2, which implies he is under nourished.

His vitals are pulse rate 78 per minute regular rhythm and normal volume, respiratory rate is 16/ min, regular breathing abdominothoracic type, his blood pressure is 114/64 in right upper limb in sitting position. No pallor, clubbing, cyanosis or pedal edema.

Systemic examination of cardiovascular system, inspection of chest revealed no dilated veins or any scars, first and second heart sound heard in all cardiac areas, no murmur ascultated. Then examination of respiratory system on inspection bilateral equal movements of chest, not tachypnoeic, on ascultation there is bilateral equal air entry on both lungs with no added sound.

Gastrointestinal system examination , on inspection there is normal abdominal movement with respiration, there is a scar in the right illiac fossa, no dilated veins.

On palpation of abdomen there is diffuse abdominal pain, not localized to any of the quadrant, bowel sounds present on ascultation.

Central nervous system examination , the patient is conscious and alert, inspection showed no muscle wasting or ptosis , motor power of both side upper and lower limb is 5/5, no focal neurological defecit.

Diagnosis: inflammatory bowel disease with undernourishment

His complete blood count was done it showed elevated total count, hematocrit, reduced hemoglobin , decreased serum sodium and potassium, and normal platelet count. Fecal occult blood test is negative.