2. CASE PRESENTATION
SUBJECTIVE DATA :
Name of the patient : Ramesh sinha
Age : 20 Years
Gender : Male
Occupation : Auto driver
Address : Karwan.
Habits : 1.smoking : 2.Alcohol :
Diet : Consumes Fast food and Fried diet daily both veg and non-veg.
Complaints : Patient was apparently asymptomatic 4 days before admission to hospital
then came with a history of “Bloody stools” , “loose motions” , “Abdominal
pain” , “Vomiting” and “Low grade fever” since 4 days.
Provisional diagnosis : Amoebiasis ? , Hemorrhoids ? Fissure ?.
5. MICROBIOLOGICAL INVESTIGATION:
Direct microscopy of stool :
1.Tetranucleate cysts of Entamoeba histolytica
were detected containing RBCs in their food
vacuole.
2. Stool with blood and mucus.
6. COLONOSCOPY :
Flexible colonoscopy :
1. Colonoscopy reveals “Erythma” with “Erosions”
noted in rectum and “Loss of vascular pattern”
2. Multiple polypoid lesions noted in sigmoid
colon throughout the procedure.
7. HISTOLOGICAL INVESTIGATION :
Recto-sigmoid Biopsy :
1. Bits of colon mucosa with “Glands lined by
epithelium” .
2. Ulceration
3. Crypt distention and crypt abscess
4. Infiltration in the “Lamina propia”.
→ USG- Abdomen : Normal
8. ASSESSMENT
The Diagnosis is made on above Laboratory,
Microbiological, Colonoscopy and Histological
investigation as :
Final diagnosis → Inflammatory bowel disease
“Ulcerative colitis” in
particular.
→ “Amoebiasis”.
9. PLANNING :
DAY-1
Forml Drugs Generics Dose `Route Freq
TAB DOLO650 PARACETAMOL 650MG P/O TID
INJ METROGYL METRONIDAZOLE 100 ML IV TID
IVF NS NORMAL SALINE 2 BOTTLE IV BD
INJ PANTOP PANTAPRAZOLE 40 MG IV BD
INJ ZOFER ONDENCETRON 100 MG IV TID
TAB SPORLAC LACTOBACILLUS
SPORES
--------------- P/O BD
INJ BUSCOPAN HYOSCINE BUTYLE
BROMIDE
2 CC IV BD
TAB IFA IRON AND FOLIC
ACID
--------------- P/O BD
11. INDICATIONS:
1.Dolo650: Paracetamol
It is an NSAID (Antipyretic),given to reduce fever
2. Metrogyl : Metronidazole
Antibiotic for Amoebiosis
3. Pantop : Pantaprazole
PPI to reduce acid production
4. zofer : ondencetron
Anti-emetic prescribed for vomiting
5. sporlac : lactobacillus spores
To maintain gut floral integrity
6. Buscopan : Hyoscine butyle bromide
Anti-spasmodic prescribed for abdominal pain
7. IFA : Iron and folic acid
Prescribed for low haemoglobin value.
14. PATIENT COUNSELING:
1.For Disease State:
What is ulcerative colitis?
It is an autoimmune disease affecting sigmoid and descending
colon and may also affect rectum resulting in mucopurulent,
erythmatous and granular superficial ulceration.
.
2.For Medication
patient is adviced to take prescribed medications regularly
without fail & do not take double dose, if a dose is missed.
3.For Life Style Modification:
Diet- Low fiber diet , low lactose diet