Question: Answer This Case Questions Chief Complaint“I Can’t Take The Pain And Diarrhea Anymore. I Thought I Could Make It Until I Got Home To See My Doctor But Today I Realized I Needed To See Someone.”HPIBonnie Smith Is A 32-year-old Woman Who Presents To The ED With The Chief Complaint Of A 1.5-week History Of Abdominal Pain Associated With Cramping, …

Question: Answer This Case Questions Chief Complaint“I Can’t Take The Pain And Diarrhea Anymore. I Thought I Could Make It Until I Got Home To See My Doctor But Today I Realized I Needed To See Someone.”HPIBonnie Smith Is A 32-year-old Woman Who Presents To The ED With The Chief Complaint Of A 1.5-week History Of Abdominal Pain Associated With Cramping, …

answer this case questions

Chief Complaint

“I can’t take the pain and diarrhea anymore. I thought I could makeit until I got home to see my doctor but today I realized I neededto see someone.”

HPI

Bonnie Smith is a 32-year-old woman who presents to the ED with thechief complaint of a 1.5-week history of abdominal pain associatedwith cramping, bloody diarrhea, and mucus that she states istypical of her UC flares. She states that she has been having aboutfour bloody bowel movements a day for most of the time that she hasbeen in our city on vacation, but today she was dizzy when shestood up; she did not have any symptoms while sitting or lyingdown. She has been here on vacation for almost 2 weeks and isscheduled to return home in 3 days. She has not traveled outsidethe country, been hospitalized, or received antibiotics recently.She was diagnosed with UC approximately 3 years ago and has hadapproximately one exacerbation a year that her physician hastreated with Pentasa capsules four times a day during eachexacerbation. Each time her symptoms have resolved with 4–6 weeksof therapy. She has refused maintenance therapy because she doesnot want to take a medication four times a day; it is not conduciveto her work and social life and she has refused rectal medicationsfor the same reason. Her last exacerbation was approximately 10months ago.

PMH

UC, diagnosed 3 years ago

Type 1 DM

FH

Mother has a history of CAD and lung CA; father has a history ofUC, S/P colectomy 18 years ago.

SH

Works as an office manager; lives with her fiancée; no children;denies tobacco use; drinks one to two glasses of wine every fewweeks; acknowledges marijuana use from 2005 to 2008 but states nonein the past 10 years

Meds

Insulin aspart via insulin pump; settings per endocrinology.

Vaccination history is unavailable.

All

NKDA

ROS

Negative for chest pain, SOB, dysuria, fever, chills, N/V,myalgias, arthralgias, polyuria, or recent allergic reaction.Positive for mild abdominal soreness, cramping, and intermittentbloody diarrhea with occasional urgency.

Physical Examination

Gen

A&O, pleasant, healthy-appearing Caucasian woman in NAD

VS

At 8 <small class=”uppercase” style=”font-size:12.800000190734863px;font-family:’Source Sans Pro’, sans-serif;”>AM</small>:

BP (lying down) 100/58 mm Hg, P 60 bpm

BP (standing) 80/40 mm Hg, P 75 bpm

RR 18/min, T 37.0°C

Wt 145 lb (66 kg), usual weight 150 lb (68 kg); Ht 5′7″ (170 cm);BMI 23.5 kg/m2

Skin

No lesions; warm, adequate turgor

HEENT

PERRLA; EOMI; mucous membranes without lesions or exudates; TMsintact

Lungs

CTA, no rales or rhonchi

CV

RRR, normal S1and S2;no S3,S4

Abd

Normal active BS, soft, nondistended; tender to deep palpation butno palpable mass; no liver or spleen enlargement; no reboundtenderness or guarding

Rect

Somewhat tender; no hemorrhoids, fissures, or lesions by anoscopy;heme (+) stool

MS/Ext

No CCE; pulses 2+; normal ROM; strength 5/5 bilaterally

Neuro

A&O × 3; CN II–XII intact; DTRs 2+

Labs

At 10:00 <small class=”uppercase” style=”font-size:12.800000190734863px;font-family:’Source Sans Pro’, sans-serif;”>AM</small>:

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Na 137 mEq/L

Hgb 13 g/dL

WBC 5.5 × 103/mm3

AST 22 IU/L

K 3.4 mEq/L

Hct 38%

PMNs 52%

ALT 20 IU/L

Cl 105 mEq/L

Plt 242 × 103/mm3

Bands 5%

Alk phos 36 IU/L

CO227 mEq/L

MCV 85.3 μm3

Lymphs 36%

T. Bili 0.5 mg/dL

BUN 26 mg/dL

MCH 29.1 pg

Basos 1%

PT 12.0 s

SCr 1.0 mg/dL

MCHC 34.1 g/dL

Monos 6%

INR 1.0

Glu 113 mg/dL

Ca 8.9 mg/dL

Mg 1.9 mEq/L

PO44.2 mg/dL

Alb 3.9 g/dL

A1C 6.2%

Fecal calprotectin: 160 mcg/g

Urinalysis

Color yellow; transparency clear; negative for protein, leukocyteesterase, nitrite, blood, ketones, RBCs, WBCs, and bilirubin; pH7.0; specific gravity 1.019

Assessment

Lower GI bleeding with a history of UC in a patient who hasdeclined maintenance therapy in the past

D/C with instructions to return to ED if symptoms worsen and tocontact PCP on return home

Clinical Course

The patient presents to her local PCP for follow-up 1 month afterher initial presentation to the ED. She states that her bowelmovements are “completely normal,” and she no longer has pain. Shestates that the symptoms started to resolve about 2 weeks after shestarted treatment. She has had no further complaints of weakness ordizziness. The repeat Hgb today is 12.9 g/dL.

Collect Information

1.a.

What subjective and objective information indicates the presence ofactive UC?

1.b.

What additional information is needed to fully assess the patient’sUC?

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Assess the Information

2.a.

Assess the severity of the UC based on the subjective and objectiveinformation available.

2.b.

Create a list of the patient’s drug therapy problems and prioritizethem. Include assessment of medication appropriateness,effectiveness, safety, and patient adherence.

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Develop a Care Plan

3.a.

What are the goals of pharmacotherapy in this case?

3.b.

What nondrug therapies might be useful for this patient?

3.c.

What feasible pharmacotherapeutic alternatives are available fortreating UC?

3.d.

Create an individualized, patient-centered, team-based care plan tooptimize medication therapy for this patient’s UC and other drugtherapy problems. Include specific drugs, dosage forms, doses,schedules, and durations of therapy.

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