The patient, a 42-year-old male, presented with bloody stools, abdominal pain, vomiting and fever for 4 days. Colonoscopy revealed erythema, erosions and polypoid lesions in the colon. Histological investigations showed ulceration, crypt distention and infiltration. Stool examination detected Entamoeba histolytica trophozoites. The patient was diagnosed with ulcerative colitis and amoebiasis. He received intravenous metronidazole, pantoprazole and hydration along with lactic acid bacillus supplements. At discharge, he was prescribed a tapering course of oral metronidazole, pantoprazole and lactic acid bacillus to treat his

1. Inflammatory Bowel Disease – ULCERATIVE COLITIS
Patient Name: xxx DOA: 07/05/23
Age: 42 Y/O DOD: 09/05/23
Sex: Male
Chief Complaint (CC):
He came with H/O Bloody stools, Loose motions, Abdominal pain, Vomiting & Low-grade
fever since 4 days.
Social History:
● Non alcoholic
● No-smoker
● Does not exercise
● Auto-driver
Diet:
● Consumes fast and fried food
PHYSICAL EXAMINATION:
General Examination: Conscious, oriented, febrile.
Systemic Examination:
● CVS - S1S2 (+)
● RS - BAE (+)
VITAL SIGNS:
Vital/Date 7/05 8/05 9/05
Temp (F) 100° 100° 100°
Pulse/min 90 88 80
BP (mm/Hg) 110/70 110/70 120/70
Respiration 22 27 27
SPO2(%) 98 92 97
Laboratory Investigation:
Constituents Detected
Values
Normal Values Unit Status
Complete Blood Count
Total RBC 4 3.93 - 5.69 million cells
/ Cumm
Normal
Hemoglobin 8 11 - 18.8 g / dL Low
● P/A - Abnormal
● CNS – NFND

2. Inflammatory Bowel Disease – ULCERATIVE COLITIS
Platelet Count 297 155 - 400 10
3
/ μL Normal
ESR 18 < 20 mm/hr Normal
Department Of Biochemistry
FBS 95 99 or lower mg / dL Normal
RBS 130 less than 140 mg / dL Normal
S. Creatinine 2 0.74 - 1.35 mg/dL High
T. Cholesterol 250 less than 200 mg / dL High
Electrolytes
Sodium 133 135 - 145 mEq /L Low
Potassium 3.8 3.5 - 5.0 mEq / L Normal
COLONOSCOPY: Flexible Colonoscopy
● Colonoscopy reveals Erythma with Erosions noted in rectum & Loss of vascular
pattern.
● Multiple polypoid lesions noted in sigmoid colon throughout the procedure .
HISTOLOGICAL INVESTIGATIONS:
● Bits of colon mucosa with glands lined by epithelium.
● Ulceration.
● Crypt distention & crypt abscess.
● Infiltration in the lamina propria.
MICROBIOLOGICAL INVESTIGATIONS: Direct Microscopy of Stool:
● Tetranucleate cysts of entamoeba histolytica were detected containing RBC’s in their
food vacuole.
● Stool with blood & mucus.
DIAGNOSIS:
Main Diagnosis:
 ULCERATIVE COLITIS (IBD)
 AMOEBIASIS
Provisional Diagnosis:
 Hemorrhoids?
 Fissure?

3. Inflammatory Bowel Disease – ULCERATIVE COLITIS
DRUG THERAPY
S.
No
Generic Name Dose ROA Freq. Day
1
Day
2
Day 3
1. Tab. Paracetamol 650 mg P/O TID ✓ ✓ ✓
2. Inj.
Metronidazole
500 mg /
100 ml
IV TID ✓ ✓ ✓
3. Inj. Sodium
Chloride
100 ml (0.9
% W/V) 2
Bottle
IV BD ✓ ✓ ✓
4. Inj. Pantoprazole 40 mg / 10
ml
IV BD ✓ ✓ ✓
5. Inj. Ondansetron 2 mg / ml IV SOS ✓ ✓ ✓
6. Cap. Lactic Acid
Bacillus
Not <120 M
spores
P/O BD ✓ ✓ ✓
7. Inj. Hyoscine
Butylbromide
2CC (0.4
mg / ml)
IV BD ✓ ✓ ✓
8. Tab. Ferrous
ascorbate folic
acid
10 mg P/O BD ✓ ✓ ✓
PLAN ON DISCHARGE:
S. No Generic Name Dose ROA Freq. Days
1. Tab. Paracetamol 650 mg
P/O
SOS
7
Days
2. Tab. Metronidazole 400 mg 1-1-1
3. Powder. Dextrolyte ORS 20 g 1-1-1
4. Tab. Pantoprazole 20 mg 1-0-0
5. Tab. Ondansetron 4 mg SOS
6. Cap. Racecadotril 100 mg 2-0-2
7. Tab. Lactic Acid Bacillus 20 mg 1-0-0
8. Tab. Ferrous ascorbate folic acid 101.5 mg 1-0-1