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. ROS

4. SYMPTOMS
• Rectal bleeding, with or without mucus
• Urgency
• Tenesmus
• Lower Abdominal cramps
• Weight loss

5. HISTORY

a. FAMILY HISTORY
b. SOCIAL HISTORY
c. PAST MEDICAL HISTORY
d. SURGICAL HISTORY
e. CHRONIC CONDITIONS

6. ALLERGIES

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

8. SPECIFIC DATA LIKE GRADING

9. TESTS TO BE ORDERED
• CBC
• Urinalysis
• Platelet count
• C-reactive protein
• Albumin
• Potassium
• Magnesium
• Alkaline phosphatase
• Abdominal radiograph
• Barium enemas
• USG abdomen
• CT scan
• 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