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APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
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Topic:

Objective Data Leading to a Proctosigmoiditis Diagnosis

Case Study Instructions:

Scenario
A.O. is a 28-year-old woman who presents to your clinic with complaints of rectal bleeding and weakness. Five days ago, she noticed bright red blood in her stools. Furthermore, she reports that her daily bowel movements have increased to five or six with significant diarrhea. She has been weak for approximately three days. She has not traveled outside of the city, been hospitalized, or received antibiotics recently.
A proctosigmoidoscopy was conducted three days after the patient's discharge from the acute care clinic. A significant pseudopolyps formation could be seen. Biopsies of the colon revealed erosions of the mucosa and ulcerations into the submucosa with mixed acute (i.e., neutrophils) and chronic (lymphocytes and macrophages) inflammatory cells. No dysplastic cells suggesting the development of colon carcinoma were seen. No multinucleated giant cells suggesting Crohn's disease were seen. Inflammation and ulceration were limited to the rectum and sigmoid colon only. Crypts of Lieberkühn were intensely inflamed. Marked hemorrhaging of capillaries in the mucosa was also observed.
Laboratory Blood Test Results
Na+ = 143 meq/L
BUN = 20 mg/dL
Plt = 315,000/mm3
AST = 33 IU/L
K+ = 3.2 meq/L
Cr = 1.1 mg/dL
PO4-3 = 4.0 mg/dL
ESR = 24 mm/hr
ALT = 41 IU/L
Cl- = 108 meq/L
Hb = 10.8 g/dL
CRP = 1.5 mg/dL
T bilirubin = 0.9 mg/dL
Alb = 3.1 g/dL
HCO+3 = 18 meq/L
Hct = 36%
Ca+2 = 8.9 mg/dL
PT = 11.3 sec
Glu, fasting = 132 mg/dL
WBC = 9,400/mm3
Questions
What is the relevance of the last sentence in the first paragraph: "She has not traveled outside of the city, been hospitalized, or received antibiotics recently"?
Explain your answer in detail.
What is the diagnosis? Explain your answer. Why and how did you come up with this diagnosis?
Identify eight abnormal laboratory blood test values and provide a brief pathophysiological explanation for each of them.

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Case Study
Relevance of the Last Sentence
The last sentence is relevant since it provides accurate information about the client's condition. It justifies the impact the patient's condition has on her movements. It also offers vital measures which must be considered when addressing the patient's condition. Besides, it justifies the need for emergent actions on the patient's condition. Based on the provided information, the client suffers from a gastrointestinal problem, and the provided information such as recent traveling is significant to determine the accurate measures and diagnosis. Gastrointestinal illness impacts an individual's movement, and thus relevant information such as the history of travel is necessary (Mueller et al., 2019). Therefore, the feasible importance of the last sentence is to ensure a reliable treatment plan.
Diagnosis
The effective diagnosis for the client is proctosigmoiditis. Proctosigmoiditis is detrimental and adversely impacts the sigmoid colon, connecting the large intestine to the rectum (Yamamoto, 2019). Therefore, it affects the rectum, which is responsible for expelling the stool from the body and leads to symptoms that the patient expresses in the case study. Some of these symptom...
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