GI Case Study: Crohn's Disease SOAP Note and Management
This case study presents a two-visit clinical encounter for a 34-year-old Black woman with recently diagnosed Crohn's disease managed with Remicade (infliximab). The first visit addresses new complaints of chest pain and leg cramps alongside elevated blood pressure, outlining differential diagnoses, potential Remicade complications, and an immediate action plan. The second visit focuses on laboratory monitoring for Crohn's disease, cholesterol management with statins, lipid metabolism changes associated with inflammatory bowel disease, pharmacological options for comorbid anxiety and depression, and medications that may worsen Crohn's disease. Together, the two visits illustrate a comprehensive, patient-centered approach to managing a complex GI patient with multiple comorbidities.
- Visit 1: Subjective History and Clinical Questions: Chief complaint, Crohn's history, and follow-up questions
- Visit 1: Objective Findings: Full physical exam findings across all systems
- Visit 1: Assessment and Differential Diagnoses: Differential diagnoses and Remicade complication risks
- Visit 1: Plan and Management: Immediate tests and long-term treatment planning
- Visit 2: Laboratory Monitoring and Follow-Up Labs: Lab panels for Crohn's monitoring and follow-up
- Visit 2: Cholesterol, Mental Health, and Medication Considerations: Statin therapy, SSRI selection, and drug–disease interactions
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What makes this paper effective
- The SOAP note format is applied rigorously across both visits, providing a clear and clinically authentic organizational structure that mirrors real-world practice documentation.
- Each clinical decision is supported by reasoning tied to the patient's specific history — family history of MI, smoking, Remicade initiation — demonstrating individualized, evidence-based thinking rather than generic protocols.
- The second visit systematically addresses multiple comorbidities (dyslipidemia, anxiety, hypertension) with specific drug recommendations and monitoring timelines, showing depth of pharmacological knowledge.
Key academic technique demonstrated
The paper effectively uses clinical differential diagnosis reasoning, listing multiple plausible etiologies (e.g., angina, costochondritis, GERD for chest pain; DVT, PAD, electrolyte imbalance for leg pain) and then systematically narrowing the workup. This technique — generating and ranking differentials before committing to a plan — is a hallmark of graduate-level clinical reasoning in nursing and medical education.
Structure breakdown
The paper is divided into two clinical visits. Visit 1 follows the standard SOAP format: Subjective (chief complaint, history), Objective (physical exam findings), Assessment (differential diagnoses and Remicade complication awareness), and Plan (immediate and long-term actions). Visit 2 is organized as a numbered clinical question-and-answer series covering lab selection, cholesterol pharmacotherapy, statin monitoring, IBD–lipid interactions, mental health prescribing, and drug–disease interactions. References follow APA style throughout.
Visit 1: Subjective History and Clinical Questions
A 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 (infliximab) infusions for Crohn's disease approximately three weeks ago and is currently in remission. She reports no rectal bleeding at present. She quit smoking three weeks ago after starting Remicade. She had smoked one pack of cigarettes per day since age 20.
Visit 1: Objective Findings
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°F, 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 ×4. 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.
Visit 1: Assessment and Differential Diagnoses
Chest Pain: Given the patient's family history of myocardial infarction at a young age, her recent history of smoking, and her elevated blood pressure, cardiac causes must be ruled out.
Leg Cramps: Differential diagnoses include electrolyte imbalances, peripheral vascular disease, deep vein thrombosis, and medication side effects (Lam et al., 2022).
Hypertension: Blood pressure is elevated at 148/94. Given the family history of hypertension, this requires further attention and management.
Crohn's Disease: Currently in remission after starting Remicade.
Angina/Myocardial Infarction: Given family history and smoking history, cardiac ischemia must be considered. Costochondritis: Inflammation of the cartilage in the rib cage may present as chest pain. Gastroesophageal Reflux Disease (GERD): Can cause chest pain that mimics cardiac 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.
Infections: Remicade can reduce the immune system's ability to fight infections. Liver problems: Symptoms may 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 may include persistent fever, bruising, bleeding, or pallor. Lupus-like syndrome: Symptoms include chest discomfort or pain that does not resolve, shortness of breath, joint pain, or a rash on the cheeks or arms that worsens in sunlight (Roller & Gowan, 2019). Nervous system problems: Symptoms may include numbness, weakness, tingling, vision problems, and seizures.
Visit 1: Plan and Management
Obtain an EKG to rule out cardiac causes of chest pain. Check electrolyte levels to rule out causes of leg cramps. Perform a D-dimer test or ultrasound of the legs to rule out DVT if clinically indicated.
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 hepatic complications of Remicade. Recommend a low-sodium 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.
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