Management of Inflammatory Bowel Disease Essay

Management of Inflammatory Bowel Disease Essay

J.K is a 19-year-old African American female. She presented in the office with complaints of abdominal pain in the right lower quadrant. It was of acute onset radiating to the periumbilical region and the left lower quadrant. The pain was on a scale of 4 out of 10 that had reduced from 9 out of 10. The pain was so severe that the patient could neither go to work nor eat. The pain was aggravated by eating or exertion and was relieved by rest and taking pain killers. The patient complained of vomiting that was post-prandial. It was non-projectile, not blood-stained, non-foul smelling, and contained food content or water. It was associated with nausea, abdominal bloating, alternating episodes of diarrhea, and constipation. The patient reports loose mucoid stool with a few fresh bloodstains associated with tenesmus. The patient also reports general body weakness. However, there is no recorded history of weight loss, reflux, and heartburn Management of Inflammatory Bowel Disease Essay

Past Medical and Surgical History

The patient is known to have diabetes mellitus type one and is on mixtard insulin. No history of admission in the hospital and blood transfusion. There is no known history of food and drug allergy. The patient has not undergone any minor or major surgical procedure.

Personal Social Economic History

J.K is a 19-year-old African American female who is a college student and an active member at a city protestant church. She is the firstborn in the family and stays with her parents and two brothers. She does not take alcohol or use drugs and other substances. Her mother is known to have diabetes and is on treatment while his father has coronary heart disease.

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Gynecological and Obstetric History

Her menarche was at the age of 14 years. Her menstrual cycle is regular every 28 days, with four days of normal flow and no history of dysmenorrhea. She neither has a sexual partner nor has ever engaged in sexual intercourse.

Review of Systems

The affected system is gastrointestinal that presents with abdominal pain on the right lower quadrant associated with nausea, vomiting, alternating episodes of diarrhea and constipation, and abdominal bloating. The respiratory, cardiovascular, genital-urinary, and musculoskeletal systems are not affected.

Objective Data

General Examination

She is an obese African American young lady who is clinically afebrile. However, she is not pale, jaundiced, dehydrated, cyanosed, and has no lymphadenopathy. Her vitals are; blood pressure 120/78mmHg, heart rate 122 beats per minute, oxygen 98% in room air, and temperature at 37.2 degrees celsius. Management of Inflammatory Bowel Disease Essay

Systemic Examination

Gastrointestinal system: the abdomen is moving with respiration, with normal contour, no obvious mass, and scars. On auscultation, the bowel sounds are present and hyperactive. On palpation, there is tenderness at the right lower quadrant on deep palpation and there is no palpable mass. There is a tympanic note on percussion in all abdominal quadrants. However, there is no shifting dullness. Normal findings are noted upon digital rectal examination. The respiratory, genital-urinary, musculoskeletal, cardiovascular, and nervous systems have normal findings upon examination.

Diagnostic Tests

A Complete blood count is done to rule out an infective inflammatory disease. Vitamin B12 evaluation, iron, folate, and other nutritional makers are done to rule out Crohn’s disease. erythrocytic sedimentation rate and C-reactive proteins are inflammatory markers done to assess the progress of the patient. Stool studies for microscopy, culture, and the occult to evaluate pathogens causing diarrhea and vomiting. Goedee, et al, (2017)Radiographic tests used to rule out ulcerative colitis, Crohn’s disease, and inflammatory bowel disease include upright chest x-ray, barium enema double contrast, abdominal ultrasound, CT scanning, and MRI. Management of Inflammatory Bowel Disease Essay

Assessment

Differential Diagnosis

Inflammatory bowel disease: K 52

Ulcerative colitis: K51

Crohn’s disease: K 50

Inflammatory bowel syndrome presents with abdominal pain, mucoid or bloody diarrhea alternating with episodes of constipation, nausea, vomiting postprandial, and tenesmus (Caruso et al, 2020). Ulcerative colitis presents with abdominal pain at the left lower quadrant associated with constipation, and rectal bleeding (Bank, et al, 2018). Crohn’s disease presents with pain on the right upper quadrant associated with nausea and vomiting. The patient reports lose mucoid stools after food ingestion.

Primary diagnosis: inflammatory bowel syndrome

Plan

Pharmacologic Treatment

Mixtard insulin 20 IU is given in the morning and 10 IU in the evening to maintain the blood sugar levels. Give Metronidazole 400mg 8 hourly for five days for prophylaxis to prevent infective bowel syndrome (Wright, et al, 2018). Prednisolone 10mg once a day for inflammatory bowel syndrome, Omeprazole 20mg 12hourly for prophylaxis to prevent gastritis, Loperamide 4mg PRN for diarrhea, Buscopan 10mg 12 hourly for pain, Plasil 10 mg 8 hourly for vomiting and nausea, and Enema suppository for constipation.

Non-Pharmacologic Treatment

Patient education inflammatory bowel disease is a long-life disease that begins in young adulthood. It is prevented through lifestyle modifying practices such as avoiding smoking tobacco and maintain healthy eating habits. The patient is advised to take food rich n fiber such as vegetables to avoid inflammatory bowel syndrome. The patient is encouraged to visit the hospital monthly for a check-up and monitoring the progress of the illness.

Reflection Notes

I would not do anything different from the diagnosis and treatment of the patient. The most challenging point was the nutritional advice for this patient since she has maturity-onset diabetes mellitus. Management of Inflammatory Bowel Disease Essay

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): This is a brief statement identifying why the patient is here in the patient’s own words, for instance, “headache,” not “bad headache for 3 days.”

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start every HPI with age, race, and gender (e.g., 34-year-old African American male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Management of Inflammatory Bowel Disease Essay

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/relieving factors: light bothers eyes, Naproxen makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include over-the-counter (OTC) or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction versus intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promotion questions here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, the condition of the living environment, text/cell phone use while driving, and support systems available. Management of Inflammatory Bowel Disease Essay

Fam Hx: Illnesses with possible genetic predisposition, contagious illnesses, or chronic illnesses. The reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual—current and historical).

Reproductive Hx: Menstrual history (date of last menstrual period [LMP]), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse (oral, anal, vaginal, other), and any sexual concerns.

ROS: This covers all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: and so forth. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. LMP: MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle pain, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising. Management of Inflammatory Bowel Disease Essay

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when conducting your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and history. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT:).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). Management of Inflammatory Bowel Disease Essay

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection a discussion related to health promotion and disease prevention, taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

Episodic Visit SOAP NOTE: A Gastrointestinal Condition Focused SOAP Note

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will work with an adolescent patient and complete a Focused Note Template (see attached template) in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.

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Assignment

Select an adolescent patient. With this patient in mind, address the following in a Focused Note. Management of Inflammatory Bowel Disease Essay

  1. Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies. Management of Inflammatory Bowel Disease Essay
  2. Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
  3. Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
  4. Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  5. Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

References

Bank, S., Andersen, P. S., Burisch, J., Pedersen, N., Roug, S., Galsgaard, J., … & Andersen, V. (2018). Genetically determined high activity of IL-12 and IL-18 in ulcerative colitis and TLR5 in Crohn’s disease were associated with non-response to anti-TNF therapy. The pharmacogenomics journal18(1), 87-97.

Caruso, R., Lo, B. C., & Núñez, G. (2020). Host–microbiota interactions in inflammatory bowel disease. Nature Reviews Immunology, 1-16.

Goede, H. S., van der Pol, W. L., van Asseldonk, J. T. H., Franssen, H., Notermans, N. C., Vrancken, A. J., … & van den Berg, L. H. (2017). Diagnostic value of sonography in treatment-naive chronic inflammatory neuropathies. Neurology88(2), 143-151.

Wright, E. K., Ding, N. S., & Niewiadomski, O. (2018). Management of inflammatory bowel disease. The Medical Journal of Australia209(7), 318-323. Management of Inflammatory Bowel Disease Essay

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