Assessing Ulcerative Colitis

IBD: Ulcerative Colitis
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IBD: Ulcerative Colitis
Patient: Mrs.Z
She is a 34-year-old white female presenting with diarrhea, abdominal pains and progressive weakness, which started four days ago.
* Subjective Data:
Chief Complaint:
The patient reports diarrhea, accompanied by abdominal pains and progressive weakness, which started four days ago.
History of present Illness
* She perceives fever but has not taken any measure.
* She is increasingly getting concerned about the progressive weakness
* Reported rising frequency of bowel movements.
* She reports blood-stained watery stool
* She denies any recent history of travel
* Has a positive history of asymptomatic ulcerative colitis
Current Medication
* Mrs. Z denies any recent history of antibiotic use
* She reports being on oral contraceptive and elm capsules
* 2-3 doses of Benefiber
* Objective Data
* BP 117/70mmhg stting , pulse 92,temperature 100.1
* Active bowel sound in all quadrant
* Mild tenderness upon palpation
* Laboratory findings: WBCs 14000:hemoglobin 11.9:Hct 35.7;sodium levels 133:postasium 3.3
* Assessment
From the patient’s data evaluation, the most probable diagnosis associated with the primary complaints, such as diarrhea, accompanied by abdominal pains and progressive weakness, is ulcerative colitis. Ulcerative colitis is s type of Inflammatory Bowel Disease (IBD). The patient reports a history of this disorder. Bloody stool, diarrhea, mucous presence, increased urgency, muscle spasm, and abdominal cramping should suggest ulcerative colitis diagnosis, especially when there is no apparent alternate cause (Rubin et al., 2019). The classic manifestations of ulcerative colitis involve bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variant degrees of abdominal pain often relieved by defecation (Gajendran et., 2019). Enteric infections such as infection with Escherichia coli E. and amebiasis should be ruled out via intestinal pathogen testing via PCR-based assays to help diagnose bacterial and viral pathogens. (Rubin et al., 2019).
A complete clinical history must entail assessing the severity of the disease, aggravating factors onset, and factors that would aid in diagnosing ulcerative colitis. Symptoms such as increasing bowel movements, high nocturnal bowel movements, bleeding in relationship with the portion of bowel movements mixed with blood should be assessed to aid in diagnosing ulcerative colitis and examining the extent of severity. Urgency, abdominal pain, weight loss, and cramping symptom...