Ulcerative Colitis

ULCERATIVE COLITIS 1.

CHIEF COMPLAINT •Ulcerative colitis

2.

HPI a. Concern: b. Onset•Sudden •Gradual c. Duration: ____ •Recent •A few days •Many days •A few weeks •Many weeks •A few months •Many months •A few years •Many years •Recurrent •N/A. d. Severity: •Mild •Moderate •Severe •Absent •Normal •Increased •Decreased •Stable •No significant change from prior visit. •Details e. Location: lower abdomen

f. Radiation:

g. Quality : •Improving •No change •Worsening •Burning pain •Constricting •Crushing •Dull pain •Heavy •Sharp pain •Squeezing •Stabbing h. Frequancy i. Status j. Context k. Aggravated by : l.

Relieved by : Bowel movement

m. Associated Symptoms •Synovitis •Ankylosing spondylitis •Sacroiliitis •Erythema nodosum •Pyoderma gangrenosum •Aphthous stomatitis •Episcliritis •Iritis •Primary sclerosing cholangitis (PSC) •Uric acid renal stones n. Pertinent Negatives o. Notes

3. 4. • • • • •

5. a. b. c. d. e. 6.

ROS SYMPTOMS Rectal bleeding, with or without mucus Urgency Tenesmus Lower Abdominal cramps Weight loss HISTORY FAMILY HISTORY SOCIAL HISTORY PAST MEDICAL HISTORY SURGICAL HISTORY CHRONIC CONDITIONS ALLERGIES

7. PHYSICAL EXAMINATION Physical findings •Mild tenderness in the lower left quadrant •Fever •Tachycardia •Weight loss 8. 9. • • • • • • • • • • • •

SPECIFIC DATA LIKE GRADING TESTS TO BE ORDERED CBC Urinalysis Platelet count C-reactive protein Albumin Potassium Magnesium Alkaline phosphatase Abdominal radiograph Barium enemas USG abdomen CT scan

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Stool studies Upper GI endoscopy Flexible sigmoidoscopy Colonoscopy Mucosal biopsy

10. ASSESSMENT/PLAN •Total colectomy 11. EDUCATION •Take nutritious diet •Restrict fiber diet •Take iron supplements 12. MEDICATION •Infliximab •Azathioprine •Cyclosporine •6-Mercaptopurine •Ciprofloxacin •Metronidazole •Methylprednisolone •Prednisone •Sulfasalazine •Balsalazide •Mesalamine •Dipentum •Asacol •Pentasa •Colazal •Rowasa enema •Canasa suppositories •Aminosalicylates •Sulfasalazine 13. FOLLOW UP