582943

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BSN, RN

Name:

Alex Monroe

MRN:

582943

Admitting Diagnosis:

Crohn's Disease Exacerbation

Room Number:

205

Isolation:

none

Code Status:

Full Code

Weight:

145 lbs

Height:

5'10

Alex Monroe

24 years old

Male

Provider:

Dr. Emily Carter, MD

Allergies:

Penicillin

Emergency Contact:

Jamie Monroe, XXX-XXX-4567

Insurance:

Private PPO

Chief Complaint

Severe abdominal pain, persistent diarrhea, and unintentional weight loss over the past month.

Medical History

- Diagnosed with Crohn's Disease at age 16
- History of perianal abscess (resolved)
- Past surgical resection of small bowel at age 20
- Iron-deficiency anemia
- No smoking or alcohol use

Home Medications

- Mesalamine 2.4g daily
- Ferrous sulfate 325 mg daily
- Multivitamin with folate

Patient was triaged and placed in Room 205. Initial assessment notes pale skin, fatigue, and reports of persistent diarrhea. IV access established, labs drawn, and fluids initiated.

Patient Information: Alex Monroe, DOB: 10/15/1999, MRN: 582943, 8:00 AM
CC: "Severe abdominal pain and diarrhea for three days."
HPI: The patient reports cramping abdominal pain, mainly in the RLQ, rated 8/10. Pain is constant and worsened by eating. He has had 8-10 episodes of diarrhea daily, watery but without blood. Unintentional weight loss of 6 lbs in the last two weeks. No fever, nausea, or vomiting.
PMH: Crohn's disease, iron-deficiency anemia, bowel resection at age 20.
FH: Mother has rheumatoid arthritis.
SH: Lives alone, works remotely. No tobacco or alcohol use.
ROS: Positive for fatigue and abdominal pain. Negative for fever, chills, vomiting.
Physical Examination:
- Vital Signs: Tachycardic, mild hypotension.
- General: Appears pale, fatigued.
- Abdomen: Distended, RLQ tenderness, hyperactive bowel sounds.
- No organomegaly. Rectal exam unremarkable.
Assessment: Likely Crohn's flare with possible dehydration and malabsorption.
Plan:
1. Admit to the medical unit for observation and hydration.
2. Order labs and imaging.
3. Start IV fluids and pain management.
4. Consult gastroenterology.

What are the likely causes of the patient's tachycardia and hypotension?

Likely due to dehydration and systemic inflammation from the Crohn's flare. Decreased intravascular volume and cytokine-mediated responses can cause these symptoms.

Based on the labs ordered, what findings would support a diagnosis of an active Crohn's flare?

Elevated WBC and CRP indicate systemic inflammation. Positive fecal calprotectin reflects intestinal inflammation specific to Crohn's disease.

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Alex Monroe

24 years old

Male

Provider:

Dr. Emily Carter, MD

Allergies:

Penicillin

Emergency Contact:

Jamie Monroe, XXX-XXX-4567

Insurance:

Private PPO

Chief Complaint

Severe abdominal pain, persistent diarrhea, and unintentional weight loss over the past month.

Medical History

- Diagnosed with Crohn's Disease at age 16
- History of perianal abscess (resolved)
- Past surgical resection of small bowel at age 20
- Iron-deficiency anemia
- No smoking or alcohol use

Home Medications

- Mesalamine 2.4g daily
- Ferrous sulfate 325 mg daily
- Multivitamin with folate

Patient resting in bed, reporting some relief with IV hydromorphone but still describes intermittent cramping. Educated patient on NPO status and bowel rest protocol. IV fluids adjusted per provider orders. Awaiting GI consult.

Patient Information: Alex Monroe, DOB: 10/15/1999, MRN: 582943, 12:00 PM
CC: Persistent abdominal pain and diarrhea.
HPI: Abdominal pain remains severe (7/10) despite IV pain medication. Reports feeling increasingly weak and fatigued. Diarrhea frequency remains 6-8 times per day.
Labs and Diagnostics:
- CBC: WBC elevated at 14.2 x 10³/µL (normal: 4.5-11 x 10³/µL).
- CRP: Elevated at 25 mg/L (normal: <5 mg/L).
- Fecal Calprotectin: Positive, highly suggestive of active intestinal inflammation.
- CT Abdomen: Significant thickening of the terminal ileum with possible partial obstruction. No perforation or abscess noted.
Assessment: Active Crohn's disease flare with complications of dehydration and possible obstruction.
Plan:
1. Continue IV fluids, increase to 150 mL/hr to address dehydration.
2. Begin bowel rest; Clear liquid diet
3. Initiate corticosteroid therapy: Methylprednisolone 40 mg IV every 12 hours.
4. Consult with GI for potential escalation to biologic therapy.
5. Repeat labs in 12 hours to monitor inflammation and hydration.

What is the rationale for initiating corticosteroid therapy in this patient?

Corticosteroids rapidly reduce inflammation by suppressing immune response, crucial in managing acute flares to prevent complications.

Why is bowel rest important in managing an acute Crohn's flare?

Reduces mechanical and chemical stimulation of the bowel, allowing inflammation to subside and preventing further exacerbation of symptoms.

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Alex Monroe

24 years old

Male

Provider:

Dr. Emily Carter, MD

Allergies:

Penicillin

Emergency Contact:

Jamie Monroe, XXX-XXX-4567

Insurance:

Private PPO

Chief Complaint

Severe abdominal pain, persistent diarrhea, and unintentional weight loss over the past month.

Medical History

- Diagnosed with Crohn's Disease at age 16
- History of perianal abscess (resolved)
- Past surgical resection of small bowel at age 20
- Iron-deficiency anemia
- No smoking or alcohol use

Home Medications

- Mesalamine 2.4g daily
- Ferrous sulfate 325 mg daily
- Multivitamin with folate

Patient educated on infliximab therapy, including potential side effects and monitoring during infusion. IV infusion initiated per protocol. Vital signs stable during administration, with no immediate adverse effects.

Patient Information: Alex Monroe, DOB: 10/15/1999, MRN: 582943, 6:00 PM
CC: Persistent but reduced abdominal pain and ongoing diarrhea.
HPI: Reports pain now at 5/10, feeling slightly less fatigued. Diarrhea frequency remains high at 4-6 episodes per day. St Clear liquids tolerated well.
Labs and Diagnostics:
- CBC: WBC trending down to 13.0 x 10³/µL.
- CRP: Improved at 18 mg/L.
- CMP: Normal electrolytes, slight improvement in albumin.
Assessment: Improvement with steroids and hydration, but underlying inflammation persists. Recommendation for escalation to infliximab therapy due to history of complications and partial obstruction.
Plan:
1. Initiate infliximab loading dose: 5 mg/kg IV infusion, given over 2 hours.
2. Monitor for infusion reactions.
3. Continue clear liquids and reassess in 12 hours.
4. Patient education on biologic therapy risks and benefits.

What are the key risks and monitoring priorities during infliximab infusion?

Risks include infusion reactions such as hypersensitivity, infection due to immunosuppression, and possible reactivation of latent infections like TB.

How does biologic therapy differ from corticosteroid therapy in managing Crohn's disease?

Biologics like infliximab target specific inflammatory pathways (TNF-alpha inhibitors), offering long-term disease control, whereas corticosteroids are for short-term symptomatic relief.

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Vital Sign	Value	Normal Range
Temperature	99.1°F	97°F - 99°F
Heart Rate (Pulse)	102 bpm	60 - 100 bpm
Respiratory Rate	20 breaths/min	12 - 20 breaths/min
Blood Pressure	98/64 mmHg	<120/<80 mmHg
Oxygen Saturation	97%	95% - 100%
Pain Level	8/10	(Subjective, scale of 0-10)

Vital Sign	Value	Normal Range
Temperature	99.3°F	97°F - 99°F
Heart Rate (Pulse)	96 bpm	60 - 100 bpm
Respiratory Rate	18 breaths/min	12 - 20 breaths/min
Blood Pressure	100/68 mmHg	<120/<80 mmHg
Oxygen Saturation	98%	95% - 100%
Pain Level	7/10	(Subjective, scale of 0-10)

Vital Sign	Value	Normal Range
Temperature	99.0°F	97°F - 99°F
Heart Rate (Pulse)	88 bpm	60 - 100 bpm
Respiratory Rate	16 breaths/min	12 - 20 breaths/min
Blood Pressure	110/72 mmHg	<120/<80 mmHg
Oxygen Saturation	99%	95% - 100%
Pain Level	5/10	(Subjective, scale of 0-10)

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