Regional enteritis of small intestine with large intestine Candidal esophagitis Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Hypopotassemia Dysphagia unspecified Dehydration
 
Name:  ___                       Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Pepcid / Sulfasalazine / metronidazole / azathioprine
 
Attending: ___.
 
Chief Complaint:
HMED Admission Note
___

cc: abdominal pain, diarrhea
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
___ year old F with Chron's disease since ___ here with weight 
loss, fever, nausea, and diarrhea. Pt with recent colonoscopy 
this month showing active disease in most of her colon with 
rectal sparing. CMV testing showed negative stain but cultures 
pending. Pt also with history of latent TB and completed 
treatment course with rifampin a few months ago. Pt started on 
prednisone for her active disease but unable to tolerate 
medication (did not like taste). She saw Dr ___ and was 
noted to have significant abdominal pain dehydration with nearly 
30 lb weight loss in the past month, fevers, and diarrhea with 
any PO intake so she was directly admitted from clinic. Says 
diarrhea is watery and foul smelling. Some dry heaving. Reports 
subjective fevers at home but has not been taking temps, reports 
pain in knees without swelling or inflammation. 

ROS: negative except as above

 
Past Medical History:
#Chrons - diagnosed in ___, never on biologics, h/o 
fistula/abscess
#HTN
 
Social History:
___
Family History:
No family history of Chron's.
 
Physical Exam:
Vitals: 100.2 117/63 127 16 100%RA
Gen: NAD, thin
HEENT: white material caking tongue but not orl mucosa, small 
ulcers in oropharynx
CV: tachy, regular, no rmg
Pulm: clear bl
Abd: quiet bowel sounds but present, soft, tenderness in RLQ 
with no rebound
Ext: no edema
Neuro: alert and oriented x 3
 
Pertinent Results:
___ 04:20PM   WBC-19.3* RBC-4.63 HGB-9.9* HCT-33.2* MCV-72* 
MCH-21.4* MCHC-29.7* RDW-16.3*
___ 04:20PM   PLT COUNT-701*#
___ 04:20PM   GLUCOSE-82 UREA N-17 CREAT-1.0 SODIUM-138 
POTASSIUM-3.5 CHLORIDE-88* TOTAL CO2-28 ANION GAP-26*
___ 04:20PM   ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-90
___ 04:20PM   ALBUMIN-3.6
___ 04:20PM   CRP-199.5*
 
Brief Hospital Course:
___ yo F with Crohn's disease here with likely flare.  We 
initially kept her NPO and started her on steroids with 
improvement.  Given concern for leukocytosis and lesions noted 
on colonoscopy, we obtained CMV viral titers and IgM/IgG all of 
which were negative.  We switched her from IV steroids to PO 
liquid prednisone to be continued at home.  We started her on 
nystatin for possible oral ___ will see her 
in follow up for remicaide infusion an outpatient (costs for 
starting remicaide inpatient were prohibitive).
  

 
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain 
2. Fluticasone Propionate NASAL 1 SPRY NU BID 
3. FoLIC Acid 1 mg PO DAILY 
4. Hydrochlorothiazide 25 mg PO DAILY 
5. Hydrocortisone Enema 100 mg PR QHS:PRN chrons 
6. lidocaine HCl-hydrocortison ac ___ % rectal TID:PRN pain 

 
Discharge Medications:
1. Nystatin Oral Suspension 10 mL PO QID:PRN thrush 
RX *nystatin 100,000 unit/mL 10 mL by mouth three times a day 
Refills:*1
2. predniSONE 30 mg ORAL BID 
RX *prednisone 5 mg/5 mL 6 mL by mouth twice a day Refills:*1
3. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain 
4. Fluticasone Propionate NASAL 1 SPRY NU BID 
5. FoLIC Acid 1 mg PO DAILY 
6. Hydrocortisone Enema 100 mg PR QHS:PRN chrons 
7. lidocaine HCl-hydrocortison ac ___ % rectal TID:PRN pain 
8. Hydrochlorothiazide 25 mg PO DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Crohn's disease flare
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
Dear Ms ___,

You were admitted for a Crohn's flare - we started you on 
steroids.  You will need to see Dr ___ in follow up - she will 
call you with an appointment - she will also be scheduling you 
for Remicaide dosing as an outpatient sometime next week.  We 
also tested you for infection (CMV) which was negative.   
 
Followup Instructions:
___

{'abdominal pain': ['Regional enteritis of small intestine with large intestine'], 'diarrhea': ['Regional enteritis of small intestine with large intestine'], 'fever': ['Regional enteritis of small intestine with large intestine'], 'nausea': ['Regional enteritis of small intestine with large intestine'], 'weight loss': ['Regional enteritis of small intestine with large intestine'], 'knee pain': []}