Professional Documents
Culture Documents
1. CHIEF COMPLAINT
2. HPI
3. ROS
4. SYMPTOMS
•Toxic megacolon
•Diarrhea
•Abdominal pain
•Rectal bleeding
•Tenesmus
•Vomiting
•Fever
5. HISTORY
•FAMILY HISTORY
a. Diabetes
b. Hypertension
•SOCIAL HISTORY
•PAST MEDICAL HISTORY
a. Ulcerative colitis
b. Pseudomembranous colitis
c. Inflammatory bowel disease
d. Infectious colitis
e. Radiation colitis
f. Ischemic colitis
g. Nonspecific colitis secondary to chemotherapy
•SURGICAL HISTORY
•CHRONIC CONDITIONS
a. Ulcerative colitis
b. Inflammatory bowel disease
6. ALLERGIES
7. PHYSICAL EXAMINATION
•Tachycardia
•Hypotensive
•Tachypneic
•Abdomen distended
•Bowel sounds decreased
•Rebound tenderness
•Abdominal rigidity
9. TESTS TO BE ORDERED
•CBP
•Chemistry panel
•Serum electrolytes
•Nutritional and coagulation panel
•C-reactive protein
•Plain abdominal radiographs
•CT scan
•Endoscopy
•Flexible sigmoidoscopy
•Colonoscopy
10. ASSESSMENT/PLAN
Surgical Care
•a total proctocolectomy
•subtotal colectomy
11. EDUCATION
12. MEDICATION
•Hydrocortisone
•Methylprednisolone
•Cyclosporine
•Ampicillin
•Gentamicin
•Metronidazole
13. FOLLOW UP