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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Describe the typical clinical presentation of active Crohn disease (CD), including signs, symptoms, and disease distribution and severity.

  • Identify exacerbating factors and potential complications of CD.

  • Recommend appropriate pharmacologic treatment for active CD.

  • Review major toxicities of drugs commonly used for managing CD.

  • Educate a patient on the proper use of medications used to treat CD.

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PATIENT PRESENTATION

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Chief Complaint

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“I’m having occasional diarrhea, sometimes with blood. I occasionally have mild abdominal pain. I feel run down lately and have lost a few pounds.”

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HPI

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John Jensen is a 32-year-old man who presents to the clinic with a 3-month history of intermittent episodes of diarrhea. He states that he has been having one to two loose bowel movements a day over this time. This is different from his typical bowel pattern. Over the past 4 weeks, he has also noticed blood in some of his stools. The episodes of diarrhea are infrequently accompanied by brief periods of mild abdominal pain. These symptoms have caused problems with his job, as he is a sales representative for a pharmaceutical company and spends a lot of time driving to appointments. He reports a 5-lb unintentional weight loss over this time period that he attributes to “not wanting to make his abdominal pain worse.” He has tried OTC naproxen for the abdominal pain and Pepto-Bismol for the diarrhea, both of which have provided little relief. He does not recall any exposure to sick contacts. He reports no recent international travel. His PCP referred him to a gastroenterologist.

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PMH

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  • GERD

  • Sinusitis (last treated with antibiotics 8 months ago)

  • Seasonal allergic rhinitis

  • Exercise-induced bronchoconstriction

  • ACL repair of the right knee 2 years ago

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FH

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Father with DM, mother with HTN. Older sister with CD.

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SH

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Single. Works as a sales representative for a pharmaceutical company. Occasional alcohol use on the weekends. Smokes 0.5 ppd × 10 years.

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Meds

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  • Loratadine 10 mg PO once daily

  • Fluticasone two sprays each nostril PRN

  • Naproxen sodium 220 mg PO Q 8–12 H PRN pain

  • Albuterol HFA MDI PRN prior to exercise

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All

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Hydrocodone (GI upset)

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Sulfa drugs (severe rash)

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ROS

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No sick contacts. Heartburn one to two times a week and rhinorrhea one to two times a week. No cough, SOB, HA, or mental status changes. No knee or joint pain. No jaundice or rashes. No mouth sores.

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Physical Examination

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Gen
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Well-developed Caucasian male in no apparent distress

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VS
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