Reference no: EM133596581
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?