A CASE PRESENTATION ON IBD (INFLAMMATORY BOWEL DISEASE)

1. INFLAMMATORY BOWEL
DISEASE:
ULCERATIVE COLITIS
PRESENTED BY.,
HASHIM SYED ALI ABBAS H
HT.NO : 170312882029
PHARM-D 6TH YEAR
MESCO COLLEGE OF PHARMACY.

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 ?.

3. OBJECTIVE DATA :
 Vital Data:
Vitals DAY-1 DAY2 DAY3
PULE
(/m)
90 88 80
BP
(mmhg)
110/70 100/70 110/70
RR
( /m)
22 27 27
Temp
( F )
100 100 100

4. LABORATORY INVESTIGATIONS:
BIOCHEMICAL INVESTIGATIONS
FBS : 95 mg/dl ( N )
RBS : 130 mg/dl(N)
S.CREAT: 2mg/dl (↑)
K+ : 3.8meq/l (N)
Na+ : 133meq/l (↓)
T.CHOL : 250mg/dl
(Increased)
HAEMATOLOGICAL INVESTIGATIONS
RBC:4 million/cumm
WBC: 8800/cumm
N : 65%
L : 29%
E : 3%
M : 2%
B : 0%
ESR : 18mm/hr (↑)
Hg : 8 mg/dl (↓)
Platelets : Adequate

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

10. DAY-2,3
 Continue same treatment (CST).

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.

12. STANDARD TREATMENT PROTOCOL:

13. PHARMACIST INTERVENTION
 No Significant Drug-Drug Interactions were found.

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