FCM Sample Write-Up #3
Term 2, Winter Quarter
Sample A

ID/Chief Concern:

XX is a 49 y.o. man with a two-year history of severe Crohn’s disease, admitted for two weeks of increased nausea, vomiting, abdominal pain, bloody diarrhea, and weight loss.

 

History of Present Illness:

XX was first diagnosed with Crohn’s disease in June of 2016 and started on adalumimab. Shortly thereafter, he experienced a life threatening episode of toxic epidermal necrolysis (TEN) attributed to adalimumab and was transferred to Harborview Hospital in Seattle for management of this problem. He had a very difficult course with the TEN, and lost 100 pounds as he slowly recovered. Since that time, he has been maintained on prednisone and has had chronic low grade abdominal pain and intermittent bloody diarrhea.

Two weeks prior to hospital admission, he experienced the sudden onset of nausea and vomiting productive of clear acidic bile, bloody diarrhea, fatigue, and 6-10/10 abdominal pain. Ten days prior to hospital admission, his gastroenterologist boosted his prednisone dose and initiated a trial of vedolizumab, which XX thinks is causing green sputum production. However, his symptoms have not improved in spite of these interventions.

XX’s symptoms have been persistent since they began two weeks ago. He has had loss of appetite, and ~10-pound weight loss. His abdominal pain is 6-7/10 which increases to 10/10 when it is exacerbated by movement. It is located mostly in the midline of both the upper and lower abdominal compartments but radiates into all four quadrants. It is alleviated somewhat by icing his abdomen. He has been having diarrhea with bright red blood and mucus several times per day throughout this recent illness exacerbation; he also sometimes notes chills with the diarrhea, but has had no fever or night sweats. XX states that these symptoms are consistent with prior Crohn’s flares.

XX gets regular iron infusions to treat anemia associated with his Crohn’s disease, and he sometimes receives blood transfusions for more acute anemic episodes. XX’s family history is positive for inflammatory bowel problems in his mother and grandmother.

XX has had no constipation and no mouth or throat ulcers. He denies any contact with others who have had GI illness, has not eaten at restaurants, and has not taken antibiotics in the last year.

Hospital course: XX underwent outpatient endoscopy and abdominal CT scan on the day of admission. Based on the results of his imaging, as well as his clinical appearance – unwell, fatigued, and malnourished – the decision was made to admit him for close follow up while adjusting his medication and providing nasogastric feeding and blood transfusion to help his malnutrition and anemia.

Past Medical History:

Major Childhood Illnesses:

Adult Medical Conditions:

Medications: (patient does not know doses)

• Vedolizumab
• Megesterol
• Prednisone
• Loperamide
• Ciprofloxacin IV (in the hospital)
• Iron infusions (Every fourth week infusions of increasing dose)
• Multivitamin
• Calcium supplement
• “Probiotic”

 

Allergies: Adalimumab caused toxic epidermal necrolysis (TEN)

Health Related Behaviors:

EtOH: No alcohol use.

Tobacco: No tobacco use.

Other drugs: No other drug use. Screening/immunization: Not asked.

Sexual History: Previously active with male and nonbinary partners, XX has had no sexual activity since his diagnosis with Crohn’s disease, states he is not focused on that at present.

Family History:

Mother: Chronic colitis, arthritis

Father: Alcoholism

Maternal grandmother: colitis

Siblings: 3 brothers and 2 sisters: no illnesses known

Social History:

XX grew up in northern Idaho until the age of seven, when he moved to Seattle; he subsequently moved to Philadelphia when he entered high school. His life has been significantly affected by his Crohn’s disease. He says that since the episode of TEN, he has flashbacks and nightmares and states that he thinks he has PTSD. He has low energy and libido, and affirms dysphoria related to his chronic disease. He identifies as a cisgender man. He lives with his husband, Paul, and 5 year old stepson.

Review of systems: Constitutional:

see HPI

Eyes: No problems noted

Ears: No problems noted

Pulmonary: + for cough for the past week, productive of yellow sputum, which patient attributes to vedoluzimab. No dyspnea or hemoptysis.

Cardiovascular: no palpitations, orthopnea, or edema

GI: see HPI

GU: no dysuria, hematuria, or frequency

MSK: no joint pain, swelling or myalgias

Heme: no history of easy or prolonged bleeding

Neuro: no headache

Skin: no rash

Psychiatric: + for dysphoria, which XX attributes to his chronic illness

 

Physical exam:

General appearance: This patient appears pale, fatigued, ill and in pain. He is lying in bed with numerous IVs and a nasogastric tube. Attentive and supportive partner participates in the interview and asks questions.

Vital signs: Temperature not checked                   BP 100/62                    P 61                     R20

Skin: Warm and dry; no lesions noted.

HEENT:

Scalp: No scalp tenderness or lesions.

Eyes: Vision 20/20 bilaterally. Red reflex present bilaterally. Symmetric corneal light reflex. Conjunctivae moist and pale. Pupils equal, round, and consensually reactive to light. Eye fields revealed normal retinal vessels.

Ears: Tympanic membranes pearly-gray with intact bony landmarks and cone of light, external ear canals clear of cerumen or discharge.

Nose: External nose free of lesions and symmetrical. No lesions or drainage of nares.

Mouth/throat: Mouth free of caries, several fillings, gums pink, throat free of erythema. Tonsils not appreciated.

Neck: No cervical lymphadenopathy, trachea midline, thyroid normal size without palpable nodules.

Chest:

• Breathes without difficulty; Symmetric respiratory excursion.
• Lung fields resonant to percussion bilaterally.
• Breath sounds clear bilaterally without wheezes, crackles, or rubs.
• No CVAT.

 

Cardiovascular:

• JVP not appreciated.
• No visible precordial activity.
• Apical impulse at midclavicular line of the 5th rib. No heaves or thrills noted.
• Normal S1, S2; no gallops; 2/6 early high-pitched systolic murmur @ LLSB without radiation.
• Carotid, radial, and femoral pulses 2+ bilaterally, no carotid bruits. Posterior tibial and pedal pulses 1+ in the left leg, 2+ in the right leg.

 

Abdomen:

• Normal bowel sounds present.
• Abdomen tympanitic in all four quadrants.
• Liver border percussed at 7 cm at RMCL
• Abdomen flat, soft; non-tender in all four quadrants.
• No inguinal lymphadenopathy appreciated.

 

Extremities/musculoskeletal: No obvious swelling of joints or asymmetry in extremities. Edema absent in all extremities.

Neurologic:

Mental status: Engaged and answering questions appropriately. Demeanor somewhat over-excitable, speaking rapidly at times and sometimes raising tone of voice.

Cranial nerves:

CNII: 20/20 bilaterally

CNIII/IV/VI: Extra-ocular eye movements intact bilaterally. CNV: Equal facial sensation and masseter strength

CNVII: Muscles of facial expression symmetric, with equal strength bilaterally.

CNVIII: Sensitive to normal speaking voice and rubbed fingers bilaterally. CNIX/X: Equal palate rise upon phonation.

CNXI: Strong neck rotation and shoulder elevation. CNXII: Tongue protrudes midline.

Motor: Normal muscle strength in upper and lower extremities. No pronator drift.

Muscle group strength	L	R
Arm flexion	5	5
Arm extension	5	5
Forearm flexion	5	5
Forearm extension	5	5
Wrist flexion	5	5
Wrist extension	5	5
Finger flexion	5	5
Finger abduction	5	5
Hip flexion	5	5
Hip extension	5	5
Hip abduction	5	5
Hip adduction	5	5
Knee flexion	5	5
Knee extension	5	5
Ankle flexion	5	5
Ankle extension	5	5

Sensory: Sensitive to light touch in all four extremities.

Reflexes:

	L	R
Triceps	2+	0
Biceps	2+	2+
Brachioradialis	2+	I.V.
Patellar tendon	2+	2+
Achilles tendon	2+	2+
Toes both downgoing

Cerebellar function: Symmetric finger to nose test without dysmetria and heel to shin test bilaterally.

Gait: Normal ambulation.

Summary statement:

This is a 49 year old man with a complex 2 year history of Crohn’s disease now presenting with two weeks of nausea, vomiting, abdominal pain, bloody diarrhea, diminished appetite, fatigue, and 10# weight loss. He appears generally ill and weak, with a normal abdominal exam and findings suggesting volume depletion and anemia (pallor and a systolic murmur).

Assessment: The most likely cause of XX’s current symptoms is a flare of his previously diagnosed Crohn’s disease that has not yet responded to higher doses of prednisone, and the initiation of Vedolizumab. His two week history of fatigue, weight loss, abdominal pain, and diarrhea are typical of Crohn’s disease, and the only Crohn’s treatment he was on was prednisone at the time these symptoms began. A less likely cause of his symptoms is infectious gastroenteritis. XX has been on prednisone, which might make him more prone to getting infections. However, he has had no fever, and no known exposure to others with GI illnesses. C. difficile colitis is more common in patients with underlying inflammatory bowel disease but the lack of antibiotics in the past year argues against this diagnosis, as does the prominent nausea and vomiting and the two week duration.

XX’s vomiting and abdominal pain could be due to small bowel obstruction, a common complication of Crohn’s disease caused by chronic inflammation and stricture formation. His continued diarrhea and lack of abdominal tenderness on exam make this diagnosis less likely.