ANSWER
Visit 1: 1. Other Inquiries to Make of the Patient
Crohn’s disease:
Could you explain any changes in the frequency, consistency, presence of blood, or mucus of your bowel movements?
Have you had any nausea, bloating, or abdominal pain?
Are you experiencing issues with fatigue, hunger, or weight loss?
How are you handling any adverse drug reactions, such as those caused by Remicade?
Leg cramps:
Do the leg cramps occur during certain periods of time, such as after working out, while you’re at rest, or while you’re sleeping?
Have you observed any redness or swelling in your legs?
Has your level of physical exercise changed recently?
Pain in the chest:
Could you provide more specific details about the chest pain, such as pressure, dullness, or sharpness?
Does your back, jaw, or arm feel the pain?
Does the pain have anything to do with eating, exercising, or stress?
Do you have nausea, vertigo, or shortness of breath in addition to your chest pain?
2. Potentially Serious Remicade Complications
Infections: As an immunosuppressant, Remicade (infliximab) may raise the risk of opportunistic infections, fungal infections, and tuberculosis.
Heart Failure: People who already have heart disease are at risk of developing heart failure or having it worsen.
Reactions to the Infusion: Some individuals have reactions to the infusion itself, such as chills, fever, rash, or trouble breathing.
Liver Toxicity: Abnormal liver enzymes or hepatitis may develop.
Cancers: Using immunosuppressive medications for an extended period of time may raise your risk of getting some types of cancer.
3. Differential Chest Pain Diagnoses
Given her history of gastrointestinal issues, she may have gastroesophageal reflux disease (GERD), which is a common cause of chest pain.
Myocardial Infarction (MI) or angina: Her mother’s family history of MI raises concerns about cardiovascular disease.
Musculoskeletal Pain: This could be caused by her previous activities or the way her body is positioned.
Panic Attack/Anxiety: Chest pain may also be caused by stress and anxiety associated with Crohn’s disease or other life conditions.
Differential Leg Pain Diagnoses
Electrolyte imbalances: Leg cramps can be brought on by dehydration or low potassium/magnesium levels, which are prevalent in Crohn’s disease patients and those using diuretics like HCTZ.
She may be more susceptible to deep vein thrombosis (DVT), which can manifest as leg pain, as a result of using HCTZ.
Given the patient’s age and smoking history, peripheral artery disease (PAD) may be taken into consideration.
Muscle Strain: If she has been more sedentary after beginning Remicade, it may be connected to physical activity or overexertion.
4. Give the patient’s care plan first priority.
Take Care of the Chest Pain: prompt assessment, including an ECG and potential referral for stress testing, to rule out cardiac problems. Examine whether her gastrointestinal symptoms have gotten worse, as Crohn’s disease or medication may be the cause.
Handle Leg Cramps: Verify serum electrolytes and make any required prescription adjustments, such as addressing any potassium, calcium, or magnesium shortages.
Keep an eye out for Crohn’s disease: As directed, continue Remicade therapy, keep an eye out for adverse effects, and teach the patient self-care techniques.
Blood Pressure Management: In light of the patient’s high blood pressure, review her antihypertensive medication (such as HCTZ) and, if necessary, titrate the dosage or add a different drug.
5. Prompt Measures for This Patient
To rule out an acute myocardial infarction, order cardiac enzymes and an ECG.
Because of her history of Crohn’s disease and her usage of HCTZ, blood should be drawn for electrolyte, liver, and kidney function tests.
Examine her medication compliance, paying particular attention to antihypertensive and gastrointestinal medications, and look for any obstacles to treatment compliance.
Emphasize quitting smoking and maintaining a nutritious diet as part of managing Crohn’s disease, and educate people on lifestyle modifications to lower blood pressure.
Visit 2: 1. Crohn’s disease lab values to keep an eye on
Check for anemia, which may be a sign of bleeding or malabsorption, using a complete blood count (CBC).
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are indicators of inflammation that can be used to gauge the severity of Crohn’s disease.
Liver function tests, or LFTs, are used to check for liver toxicity, particularly when using immunosuppressive medications.
Low albumin levels may be a sign of malnutrition, which is common in Crohn’s disease.
2. Lab values that should be ordered for this follow-up appointment
Lipid Panel: Examine her triglycerides, LDL, HDL, and total cholesterol to determine her cardiovascular risk, particularly given her cholesterol level of 280.
Basic Metabolic Panel (BMP): Assess glucose, electrolytes, and renal function, particularly in light of the use of HCTZ in the treatment of Crohn’s disease.
Liver Function Tests (LFTs): To keep an eye out for any possible liver damage brought on by her continuous pharmaceutical use, especially with Remicade.
3. If the patient’s cholesterol is still elevated, what kind of medication would you start them on?
Statin Therapy: Start her on a low-dose atorvastatin (20 mg) once daily due to her high cholesterol. There is evidence to support this medication’s ability to lower cholesterol and enhance cardiovascular health.
Prescription:
Medication: Lipitor (atorvastatin)
20 mg is the dosage.
Method: Oral
Frequency: Once a day, ideally at night because that is when the liver produces more cholesterol.
Particular Guidelines: Keep an eye out for muscle soreness, monitor liver enzymes, and stress the value of routine follow-up.
4. After beginning a dose, when should the patient’s cholesterol level be checked?
Four to six weeks after beginning atorvastatin, follow-up cholesterol levels should be checked in order to assess its efficacy and, if need, modify the dosage.
5. True or False: Crohn’s disease can change how lipids, especially cholesterol, are metabolized.
It’s true. Because Crohn’s disease causes inflammation and malabsorption, it can change how fats are metabolized, particularly when the disease is active. Changes in cholesterol levels may result from this, and they should be watched.
6. Drugs for Depression and Anxiety
Drug: 25 mg of sertraline (Zoloft) each day, with the possibility of increasing to 50 mg after two weeks, contingent on tolerance.
Path: Verbal
Regularity: Every day
Special Instructions: May be taken with or without food; full therapeutic effects may not be seen for 2–4 weeks.
Education: Keep an eye out for adverse effects include agitation, sleeplessness, and sexual dysfunction.
7. Drugs That Make Crohn’s Disease Worse
NSAIDs (nonsteroidal anti-inflammatory drugs): Because they affect the gastrointestinal mucosa and can cause flare-ups, medications like ibuprofen or naproxen can exacerbate Crohn’s disease.
Corticosteroids: Prolonged use of steroids can enhance the risk of infection, cause weight gain, and worsen osteoporosis, among other consequences that can worsen Crohn’s disease.
Opioids: May exacerbate Crohn’s disease symptoms by causing delayed stomach emptying and constipation.
Citations
Iwatani, K., and Sato, K. (2021). control of hyperlipidemia in Crohn’s disease patients. Clinical Gastroenterology Journal, 55(3), 245-250.
Asthma Global Initiative (GINA). (2020). worldwide approach to managing and preventing asthma. taken from the website https://ginasthma.org.
O’Neill, A., and Harper, D. (2019). A thorough review of Crohn’s disease diagnosis and treatment. 64(5), 1047-1060; Digestive Diseases and Sciences.
QUESTION
GI Case Study
Complete visit 1 and visit 2 for this assignment
Visit 1
A 34-year-old black female reports to clinic with c/o chest pain and leg cramps. The patient was seen by a GI specialist and was informed that she had hemorrhoids and was prescribed rectal suppositories for hemorrhoids. The patient returned to the GI doctor, and he indicated that the rectal bleeding did not resolve. The GI specialist performed a colonoscopy, and the patient was diagnosed with Crohn’s disease. The patient was started on Remicade infusions for Crohn’s disease about 3 weeks ago. The patient is currently in remission and reports no rectal bleeding.
Vital Signs: B/P 148/94, Resp 20, Temperature 99.4, O2 sat 95%, Pulse 99
Cramps in legs can be painful at times with a current pain score of 2 today in office.
No known diagnostic allergies
SH: Quit smoking 3 weeks ago after after starting Remicade. The patient smoked 1 pack of cigarettes per day since age 20.
FH: Mom passed away of a MI at age 40 years old. Father is alive and is doing well. Father has HTN controlled by Hydrochlorothiazide. No family history of GI disorders.
Your SOAP Note should include:
1. What are some additional questions would you ask the patient?
2. What are possible serious complications to Remicade?
3. Provide differential diagnoses for chest pain and differential diagnoses for leg pain.
4. Prioritize your plan of care for patient.
5. What immediate actions would you take for this patient?
Visit 2 (a SOAP note is not required for part 2, please answer questions)
The patient returns to your clinic after being hospitalized for 3 days in hospital. The patient was ordered to follow up with their primary care provider post hospitalization. The patient reports feeling better. The patient was started on an anti-hypertensive medication HCTZ 12.5 mg daily. The patient’s cholesterol was 280 and the GI specialist recommended to follow up with primary care provider to start cholesterol medication. The patient states that she is struggling with anxiety and depression because of her diagnosis of Crohn’s disease. The patient has never taken medication for anxiety or depression but is requesting medication. No suicidal ideation per patient.
1. What lab values can be ordered to monitor patients with Crohn’s disease?
2. What lab values would you order for patient during this follow-up visit?
3. Once the NP receives lab results and cholesterol and lipid levels remain elevated what cholesterol medication would you start patient?
4. When should the patient’s cholesterol level be monitored after starting dose?
5. Crohn’s disease can alter the metabolism of lipids, primarily cholesterol levels. True or False
6. What medication would you prescribe for patient for anxiety and depression.
7. What medications worsen Crohn’s disease?
Content must be supported with current evidence-based clinical practice guidelines