Differential Diagnosis for Crohn's Disease Patient

GI Case Study

SOAP Note for Visit 1

Subjective

History of the present illness: 34-year-old black female presents with complaints of chest pain and leg cramps. She was diagnosed with Crohn’s disease after a colonoscopy was performed due to unresolved rectal bleeding. She was started on Remicade infusions for Crohn’s disease about 3 weeks ago and is currently in remission. She reports no rectal bleeding at present. She quit smoking 3 weeks ago after starting Remicade. She smoked 1 pack of cigarettes per day since age 20.

Additional questions to ask the patient:

· Describe the chest pain: Is it sharp, dull, burning, or pressure-like?

· Does the chest pain radiate anywhere?

· Are there any triggers for the chest pain or leg cramps?

· Any associated symptoms like shortness of breath, nausea, or sweating with the chest pain?

· How often do the leg cramps occur? Are they in both legs or just one?

· Any recent changes in diet or activity level?

· Any history of leg swelling, varicose veins, or previous blood clots?

· Any recent travel or prolonged periods of immobility?

· Any other medications or over-the-counter supplements being taken?

Objective

GENERAL: Patient appears well-developed and well-nourished. Alert, awake, and oriented to person, place, time, and situation. No acute distress noted.

VITALS: B/P 148/94, Resp 20, Temperature 99.4, O2 sat 95%, Pulse 99.

HEENT: Normocephalic and atraumatic. Mucous membranes moist. Extraocular movements intact. Pupils equally round and reactive to light and accommodation. Tympanic membranes appear normal bilaterally. No oropharyngeal erythema or exudate.

NECK: Supple, with no jugular venous distention. No palpable lymphadenopathy. Carotid pulses 2+ bilaterally without bruits.

CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 audible with no murmurs, rubs, or gallops. No peripheral edema. Capillary refill less than 2 seconds.

LUNGS: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetrical chest expansion.

ABDOMEN: Soft, non-distended, and non-tender in all quadrants. Bowel sounds present and normal. No hepatosplenomegaly or masses palpated.

EXTREMITIES: Warm and well-perfused. No cyanosis or clubbing. Patient reports bilateral leg tenderness, more pronounced in the calf muscles. No swelling, redness, or palpable cords. Pulses 2+ bilaterally.

NEUROLOGIC: Alert and oriented x4. Cranial nerves II-XII intact. Strength 5/5 in all extremities. Sensation intact to light touch. Reflexes 2+ and symmetrical.

PSYCHIATRIC: Patient appears anxious. Reports feelings of anxiety and depression related to recent diagnosis. Denies suicidal ideation.

SKIN: Warm and dry. No rashes, ulcers, or notable lesions. No erythema around the joints.

LYMPHATIC: No palpable lymphadenopathy in cervical, axillary, or inguinal regions.

MUSCULOSKELETAL: Full range of motion in all joints. No swelling, warmth, or erythema of the joints.

Assessment

Chest Pain: Given the patient\'s family history of MI at a young age, her recent history of smoking, and her elevated blood pressure, cardiac causes need to be ruled out.

Leg Cramps: Differential diagnoses include electrolyte imbalances, peripheral vascular disease, deep vein thrombosis, and side effects from medications (Lam et al., 2022).

Hypertension: Blood pressure is elevated at 148/94. Given the family history of hypertension, this needs to be addressed.

Crohn\'s Disease: Currently in remission after starting Remicade.

Differential Diagnoses for Chest Pain:

Angina/Myocardial Infarction: Given family history and smoking history.

Costochondritis: Inflammation of the cartilage in the rib cage.

Gastroesophageal Reflux Disease (GERD): Can cause chest pain that mimics cardiac pain.

Differential Diagnoses for Leg Pain:

Deep Vein Thrombosis (DVT): Especially if pain is unilateral and associated with swelling.

Peripheral Artery Disease (PAD): Given the history of smoking.

Electrolyte Imbalance: Can cause muscle cramps.

Possible Serious Complications to Remicade:

Infections: Remicade can lower the ability of the immune system to fight infections.

Liver problems: Symptoms might include jaundice, dark brown urine, right-sided abdominal pain, fever, or severe fatigue.

Heart failure: Symptoms include shortness of breath, swelling of the lower legs, and sudden weight gain.

Blood disorders: Symptoms might include persistent fever, bruising, bleeding, or paleness.

Lupus-like syndrome: Symptoms include chest discomfort or pain that does not go away, shortness of breath, joint pain, or a rash on the cheeks or arms that gets worse in the sun (Roller & Gowan, 2019).

Nervous system problems: Symptoms might include numbness, weakness, tingling, vision problems, and seizures.

Plan

Immediate Actions

Obtain an EKG to rule out any cardiac causes of chest pain. Check electrolyte levels to rule out causes for leg cramps. Perform d-dimer or ultrasound of the legs to rule out DVT if clinically indicated.

Long-term Management

Monitor blood pressure and consider starting antihypertensive medication if consistently elevated. Continue monitoring Crohn\'s disease and response to Remicade. Consider periodic liver function tests given the potential liver complications of Remicade. Recommend a low salt diet and lifestyle modifications for blood pressure control. Consider referral to a cardiologist for further evaluation of chest pain if non-cardiac causes are ruled out. Educate the patient on the potential side effects of Remicade and when to seek medical attention.

Visit 2

1. Lab Values to Monitor Patients with Crohn’s Disease

Patients with Crohn\'s disease require regular monitoring to assess disease activity, nutritional status, and potential complications (Wilkens et al., 2021). A Complete Blood Count (CBC) is needed to check for anemia, which is common in Crohn\'s due to potential blood loss, and to identify signs of infection (Pabon-Rivera, 2023). Inflammatory markers, such as C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR), can provide insights into the disease\'s activity. Albumin levels can indicate chronic inflammation or poor nutrition. Liver function tests, including AST, ALT, alkaline phosphatase, and bilirubin, are crucial as liver problems can be associated with Crohn\'s and its treatments. Stool studies can help identify infections or blood presence. Electrolytes need monitoring, especially in patients with diarrhea, which can lead to imbalances. Iron studies, Vitamin B12, and Folate levels are essential due to potential malabsorption in Crohn\'s. Lastly, while Anti-Saccharomyces cerevisiae antibodies (ASCA) can be positive in many with Crohn\'s, it\'s typically used more for diagnostic purposes.

2. Lab Values to Order for the Patient during this Follow-up Visit

For this patient\'s follow-up, several labs are pertinent. A CBC will help monitor for potential anemia or other hematological abnormalities. CRP and ESR are valuable in gauging the inflammation related to Crohn\'s. Given the recent initiation of medications, Liver function tests are crucial. The previously noted elevated cholesterol necessitates a Lipid panel. Since the patient was started on HCTZ, a diuretic that can influence kidney function and potassium levels, a Basic Metabolic Panel (BMP) is recommended. Additionally, considering the diagnosis of Crohn\'s and its potential for malabsorption, checking Vitamin B12 and Folate levels is advisable. Lastly, Thyroid function tests, including TSH and Free T4, can be beneficial since thyroid abnormalities can influence both cholesterol levels and mood.

3. Cholesterol Medication Recommendation

For patients with persistently elevated cholesterol levels, statins are the first-line treatment. Given this patient\'s heightened cholesterol and potential increased cardiovascular risk factors, such as hypertension and a family history of early MI, Atorvastatin (Lipitor) or Rosuvastatin (Crestor) would be suitable choices. The specific dose would be determined based on the cholesterol elevation degree and any other patient-specific factors. Alongside medication, it\'s crucial to emphasize lifestyle modifications, including adopting a heart-healthy diet, engaging in regular exercise, managing weight, and promoting smoking cessation. Given the patient\'s expressed feelings of anxiety and depression, a comprehensive approach that might include therapy or counseling, in addition to or instead of medication, would be beneficial.