Lucy is a 19 year old university student. She has been admitted to hospital
Lucy is a 19 year old university student. She has been admitted to hospital with a six (6) day history of lower right quadrant abdominal cramping pain increasing with intensity, diarrhoea with blood, anorexia, fatigue, nausea and episodes of vomiting. Lucy states that she was diagnosed with Crohn’s disease at age 15. She has had two previous hospital admissions for acute exacerbations of Crohn’s disease with clinical manifestations of diarrhoea, abdominal pain and vomiting. Her Crohn’s disease has been managed with a combination of diet, medication and medical monitoring. Remission of her Crohn’s disease was maintained by oral mesalazine (Mesasal). Lucy currently rates her pain as 9/10.
On examination, Lucy was pale, her extremities were cool, and her skin was dry with poor turgor. Her abdomen was distended and tender. A mass was palpable in the lower right abdominal quadrant.
Observations on admission
• Blood pressure: 95/60
• Pulse rate: 110 beats/minute
• Respiratory rate: 22 breaths/minute
• Temperature: 37.7C
• Sa02: 98% in room air
• Weight: 62 kilograms
Height: 165 cm
• Urinalysis:
• specific gravity: 1040
• dark coloured urine
no other abnormalities note
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