English for Nursing 2

Topic 14

A PATIENT WITH CROHN’S DISEASE

Instructional objectives
The students are expected to be able to:

 answer questions related to some information stated in patient’s medical record.

 explain patient’s medical record.

Related Vocabularies
Direction. The followings are vocabularies related to the crohn’s disease. Study the vocabularies below and
practice pronounce each of them with the correct pronunciation.
crohn’s disease penyakit yang berhubungan dengan saluran pencernaan
digestive track saluran pencernaan
patchy terjadi di beberapa tempat saja
inflammation peradangan
small intestine usus halus/usus 12 jari
large intestine usus besar
reliable dapat dipercaya
cramp sakit yang melilit-lilit di bagian perut
temporomandibular sendi-sendi pada kedua sisi rahang

FACTS ABOUT CROHN’S DISEASE

Crohn’s disease is a chronic (long-term) inflammation of part of the digestive tract. The part most
commonly affected is the ileum, the last section of the small intestine, although patchy
inflammation can occur anywhere in the intestines. What causes the disease is a mystery. Some
people are more susceptible to the disease than others by virtue of their genetic make-up, and the
disease can affect more than one person in a family. However, environmental factors also seem
important in causing the disease and these may include infectious agents, and, possibly, even
dietary factors. It begins with the development in the intestine wall of patches of inflammation,
which may or may not grow or spread form one part of the system to another. For no known
reason, some of these inflamed areas heal, but they may leave scar tissue that thickens intestinal
walls and narrows the passageways.
MEDICAL RECORD OF PATIENT WITH CROHN’S DISEASE
Direction. Read and study the data below.
1. Personal Data

Client : Ms. Sonia Silver

Address : 120 Main Street, Montclair, NJ (New York) 07043
Telephone : 555 7315
Contact person : Mr. John Wellesley (boyfriend)
Person’s address : 121 Main Street, Montclair, NJ (New York) 07043
Person’s telephone : 555 7316
2. Present Health Status
2 weeks ago, Sonia felt well. She took daily medications. Maintained strict diet. Walked
to work for exercise. Enjoying the spring weather. Crampy abdominal pains started to become
bothersome. Frequency of stools made it impossible to go to work. Nausea and vomiting
continue and the patient states, “I feel weak to be out of bed.”

3. Past Health Status

General Health. At age 15 diagnosed as having regional enteritis (Crohn’s disease) after a
lengthy workup, she was hospitalized several times. Maintained on drug and diet therapy until
the present time. Saw physician approximately 1 month ago when patient thought she might be
experiencing a flare-up of Crohn’s disease. At that time, prednisone dosage was increased from
20 to 40mg/day and the patient began taking ampicillin. The symptoms have persisted and the
patient is seen at present time in acute stress.

Prophylactic Medical/Dental Care. Used to see physician every 6 months and more
frequently if necessary. “I am glad my doctor knows me and understands my history. This disease
is very frightening and embarrassing. I have no medical insurance right now, and I am really
afraid to run up a medical bill I can’t afford.” She has an annual visit to the dental hygienist.

Childhood Illnesses. Chickenpox, measles, and German measles. “That’s all I can remember.”

Immunization. Tetanus shot about 5 years ago.

 Major illnesses/hospitalizations: Admitted 3 times at ages 15 & 16, diagnosed with Crohn’s
disease and provided dietary supplementation and medication stabilization.

Current medication:
Prescription : Sulfasalazine (Azulfidine) 5 g daily in divided doses; ampicillin 2 g daily PO;
prednisone 40 mg PO OD; diphenoxylate hydrochloride/atropine (Lomotil) 5 mg PO tid; ferrous
sulfate 30 mg PO daily.

Nonprescription : Multivitamin 1 tablet daily; calcium supplement 1 tablet daily;

acetylsalicylic acid (A. S. A) 2 tabs qid for joint pant prn.

Allergies. No know allergies.

4. Elimination Pattern
Bowel: Until 2 weeks ago, Sonia had occasional diarrhea, 2-4 loose stools a day with
constipation at infrequent intervals. She states that she increased her intake of water and ate an
additional piece of fruit daily when constipation recurred. Presently, she is experiencing 7-10
loose, bloody stools with lower abdominal cramps. Small quantity with each stool.
Acknowledges the use of antidiarrheal medications as prescribed. “I’m tired of the diarrhea; it
physically exhausts me and ruins my life.”

5. Physical Examination
General Survey: Height 161.3 cm. Weight: 41 kg. Has lost 4.5 kg in the last 2 weeks. Skin dry
and itchy at times. A 25-year-old white female appearing older than stated age. She is pale and
thin and appears to be moderately anxious and in a moderate amount of discomfort. Has a
cushingoid appearance secondary to prednisone use.

Vital signs:
Temperature : 100.6o F (38.1 o C) (oral)
Pulse : 92 regular (apical)
Respiration : 18 regular
BP : 90/60 (right arm), 88/60

HEENT (Head, Eyes, Ears, Nose, Throat/Mouth)

Head Symmetrical, no palpable masses. Hair is straight brown, fine texture.
No scalp lesion noted. Face is symmetrical with cushingoid appearance. No
tenderness on palpation. Round face with cheeks appearing red.
Temporomandibular joint (TMJ) is fully mobile without crepitation or pain.
Eyes Pupils equal, round, reactive to light an accommodation (PERRLA). No tenderness
or discharge noted at puncta. Visual fields appear equal on examination. Extraocular
eye movements (EOMs) tested without nystagmus. Visual acuity is 20/20 both eyes
using hand-held chart. Does not wear glasses.
Ears Ears are symmetrically placed, equal in size and shape, without lesions or nodules.
Able to hear whisper and watch tick at 1 ft. both ears. Webber test: vibration heard
 equally well in both ears. Rinne test: air conduction twice as long as bone
conduction.
Nose Nostrils are patent; no drainage; no septal deviation noted.
Throat/mouth. Oral mucosa appears pink and dry. Tongue is midline without limited
movement. Uvula is midline with rise of soft palate on saying “ah.” Positive gag
reflex. Floor of the mouth is without lesions or soreness. Teeth are in good repair.
Tonsils are present, not enlarged.

6. Laboratory Data/Diagnostic Studies

Samples: Urine, feces, blood

7. Care Plan
Diet: After operation, NPO except medication with a sip of water.
Medication:
Erythromycin 1 g PO
Neomycin 1 g PO tid.
Lomotil 5 mg q8h prn for diarrhea
Phytonadione (AquaMephyton) 10 mg IM once a week
Meperidine hydrochloride (Demerol) 50-75 mg IM q4h prn for pain.
Intravenous Therapy
Insert a central venous line with a total parenteral nutrition (TPN) solution of
dextrose 25%, amino acids 41 g, nitrogen 6.5 g, potassium 35 mEq, sodium 50 mEq,
calcium 10 mEq, phosphate 10 mM, magnesium 8 mEq, zinc 1 mg, cooper 0.4 mg,
magnese 0.1 mg, chromium 005 mg, selenium 015 mg. Add vitamins to the first
bottle only. Give 125 ml/hr.