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 Crohns disease after a colonoscopy was performed due to unresolved rectal bleeding. She was started on Remicade infusions for Crohns 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...…weeks. This allows time to assess the medication's efficacy and make any necessary dose adjustments. Once the desired cholesterol level is achieved and stabilized, cholesterol can be monitored annually or as clinically indicated.

5. Crohns Disease and Lipid Metabolism

Crohn's disease and other inflammatory bowel diseases can alter the metabolism of lipids (Suau et al., 2022). Patients with active Crohn's disease often have decreased levels of total cholesterol, LDL cholesterol, and HDL cholesterol. The inflammation and malabsorption associated with Crohn's can influence lipid metabolism.

6. Medication for Anxiety and Depression

For a patient with both anxiety and depression, selective serotonin reuptake inhibitors (SSRIs) are often the first line of treatment, such as Fluoxetine (Prozac), Sertraline (Zoloft), and

Paroxetine (Paxil, Pexeva).

It would be important to start at a low dose and gradually increase as needed. Regular monitoring for side effects and therapeutic response should be continued. Monitor potential drug interactions and gastrointestinal side effects. Combining medication with cognitive-behavioral therapy or other forms of psychotherapy could support treatment outcomes.

7. Medications that can worsen Crohns disease

Several medications can exacerbate Crohn's disease or trigger a flare-up (Li et al., 2022). Some of these include nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, and diclofenac. These can increase intestinal inflammation. Certain antibiotics can alter gut flora and exacerbate symptoms. Oral contraceptives have been linked to increased risk of Crohn's disease, though the exact relationship is still under study. Corticosteroids could have adverse effects on the course of Crohn's disease long-term. It would be wise to review…