This document presents a case of ulcerative colitis in a 20-year-old male. Examination found bloody stools, abdominal pain, and fever. Tests confirmed the presence of Entamoeba histolytica in stool and detected ulceration and crypt abscess on biopsy. The patient was diagnosed with ulcerative colitis and amoebiasis. Treatment included antibiotics, a PPI, antispasmodics, and supplements. The patient was counseled on his condition, medications, and recommended dietary changes.

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