Ulcerative Colitis Patient Medical Assessment

Advanced Health Assessment: Ulcerative Colitis Patient

The client is a 47-year-old male ulcerative colitis (UC) patient admitted to the emergency room with extreme abdominal pain. He does not have prescription or medical insurance and has not taken his medication for several months.

Relevant Additional Subjective Information

Sources contend that inflammatory bowel disease (IBD) patients are often embarrassed to discuss their symptoms with their physicians or nurses (Hibi et al., 2020). To optimize individual treatment, therefore, physicians and nurses may have to actively query their patients about all possible symptoms (Hibi et al., 2020).

To adequately capture the history of present illness (HPI), therefore, the nurse will include information on whether the patient has experienced any other symptoms of UC, including diarrhoea, fecal incontinence, nausea and vomiting, diarrhoea associated with mucus or blood, constipation, and tenesmus, among others. Understanding the full range of symptoms would provide the nurse with a clearer view of the extent of the disease and the impact on the patient’s overall quality of life. It may also be appropriate to provide details about the patient’s pain, such as its locality or whether it begins from one end of the abdomen and moves to another (McDowell, Farooq & Haseeb, 2022). UC presents with pain in the lower left quadrant, while Crohn disease presents with pain in the lower right quadrant (McDowell et al., 2022). Thus, obtaining information about the location of the patient’s pain would provide a subjective basis for determining whether or not to test for Crohn disease.

The nurse may also need to document information on the patient’s exposure to environmental and genetic risk factors. They need to indicate where the patient lives, and whether or not the patient smokes cigarettes, has a history of gastroenteritis, has undergone hormone replacement therapy, and so on. Furthermore, it may be appropriate to document whether the patient’s family has a history of UC, which predisposes them to the disease (Ungaro et al., 2016). This information would help the nurse contextualize the patient’s illness, and determine whether it is a result of genetic factors or exposure to environmental and lifestyle-related risk factors (Ungaro et al., 2016). Consequently, it would provide a more effective means to advice on proper disease management.

It may also be appropriate for the nurse to obtain information on the patient’s medication history. Aminosalicylates are the first-line treatment for mild to moderate UC, while corticosteroids are used for moderate to severe cases or where aminosalicylates prove ineffective (McDowell et al., 2022). Patients who fail to respond to corticosteroid therapy may be exposed to immune-modifying agents (anti-TNF agents) with aminosalicylates as maintenance therapy (McDowell et al., 2022). The medication history would provide a view of the patient’s disease progression and severity over time.

Additional Objective Information

Dehydration, tachycardia, and anaemia are common among UC patients (McDowell et al., 2022). For this reason, the nurse may order an electrocardiogram (EKG) test and chest x-rays to test the regularity of the patient’s heart rate and rule out tachycardia. The EKG findings will be need to be included as part of the patient’s objective information.

Further, a complete blood count could be ordered to test for the presence and severity of anaemia, as well as thrombocytosis, leucocytosis, and iron deficiencies, which are commonly elevated among UC patients (Ungaro et al., 2016). At the same time, a urine test (urinalysis) may be appropriate to show whether or not the patient is dehydrated and the degree of dehydration, especially if pallor is present (McDowell et a., 2022). The findings of both the urine test and complete blood count will need to be included as part of the objective information.

Enteric infections such as emebiasis, intestinal tuberculosis, and giardia may cause abdominal pain and diarrhea in the same way as UC (McDowell et al., 2022). As such, the nurse may order a stool assessment, such as a stool culture test, to rule out infections resulting from enteric bacteria. In this case, the findings of the stool tests will also be included as part of the patient’s objective information (McDowell et al., 2022).

To test for the presence of UC, the nurse will order an endoscopy with biopsies (Ungaro et al., 2016). They will take at least two biopsies from six different areas: the rectum, sigmoid colon, descending, ascending transverse, and terminal ileum (Ungaro et al., 2016). Any suggestive findings from the conducted endoscopy will need to be included as part of the objective information. Findings that would be considered suggestive would include paneth cell metaplasia, mucin depletion, basal plasmacytosis crypt shortening, and crypt architecture (Ungaro et al., 2016).

The Assessment and Need for Further Diagnostics

The assessment is supported by the subjective information, but gaps still exist in the objective information. First, the endoscopy may indicate the presence of UC, but may not show the severity and extent of the diagnosis (Lamb et al., 2021). Further, sources acknowledge that UC will often present with more or less the same symptoms as Crohn disease and as such, there may be a need to conduct further diagnostics to rule out Crohn disease.

Both of these gaps could be addressed through a further full ileocolonoscopy (Lamb et al., 2021). The nurse may order a full ileocolonoscopy if the endoscopy shows the presence of backwash ileitis, which is an inflammation of the terminal ileum, and a likely indicator of Crohn Disease (Lamb et al., 2021). The full ileocolonoscopy will confirm the diagnosis of Crohn disease versus UC, and indicate the severity and extent of the disease (Lamb et al., 2021).

Differential Diagnosis

Three possible differential diagnoses in the examination of UC could be Crohn disease, appendicitis, and irritable bowel syndrome (Ungaro et al., 2016; McDowell et al., 2022). Like UC, Crohn disease is a form of inflammatory bowel disease (McDowell et al., 2022). However, the two differ based on their depth in the bowel wall and location (McDowell et al., 2022). UC affects the colonic mucosa, while Crohn disease most often affects the rectum although it may also spread to the entire colon and terminal ileum (McDowell et al., 2022). However, the presenting patient is unlikely to be suffering from Crohn disease because then, the chief complaint would have been abdominal pain accompanied by occult blood and/or rectal prolapse, rather than isolated abdominal pain.