Consultatie

Medische voorgeschiedenis: -------------------------- - 1 November 2024: Patient reports a history of Crohn's disease diagnosed in 2018, managed with infliximab infusions. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Crohn's disease, diagnosed 2018, managed with infliximab. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Last consultation on 15 October 2024, patient reported stable disease. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Crohn's disease, status post ileocolectomy in 2019. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Father with history of colon cancer. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Patient denies smoking, drinks alcohol occasionally. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - No known allergies. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Up to date on all vaccinations. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - No other relevant history or contributing factors. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Double check: exams from context must not be placed here. Summarize an exam only if it is relevant, important, and explicitly mentioned as past information.) Huidige problematiek: --------------------- Patient presents today with complaints of abdominal pain and increased frequency of bowel movements. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient is here today for a follow-up regarding their Crohn's disease and recent symptoms. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Abdominal pain is located in the lower right quadrant, described as cramping, and occurring several times a day. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient reports that the pain is not relieved by over-the-counter medications. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Symptoms have worsened over the past two weeks. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient reports similar episodes in the past, but not as frequent. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Symptoms are impacting daily activities, particularly work. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Associated symptoms include fatigue and occasional nausea. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Thuistherapie: -------------- - Infliximab 5mg/kg every 8 weeks. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Infliximab, Vitamin D supplement. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Klinisch onderzoek: ------------------- - Abdomen soft, with mild tenderness in the right lower quadrant. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - BP 120/80, HR 78, Temp 37.0 C. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Abdomen: Mild tenderness in the right lower quadrant. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Each system should be separated line by line.) - BMI: 24.5. (Only include if explicitly mentioned or if weight and length are directly provided in transcript, contextual notes or clinical note; otherwise omit completely. Do not calculate unless explicitly stated.) Onderzoeken: ------------ Colonoscopy scheduled for next week. Besluit: -------- Patient presents with a flare-up of Crohn's disease, as evidenced by abdominal pain, increased bowel movements, and fatigue. The main diagnosis is Crohn's disease exacerbation. A colonoscopy is planned to assess disease activity. Treatment includes continuing infliximab infusions and symptomatic management. The patient was advised to monitor symptoms and contact the office if symptoms worsen. Follow-up in 4 weeks. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs.) Additional issues or conditions: Follow the same structure as above if applicable. Additional notes: - Patient was educated on the importance of medication adherence and recognizing signs of a flare-up. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Patient instructed to seek immediate medical attention if they develop a fever, severe abdominal pain, or bloody stools. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Patient expressed concerns about the impact of their symptoms on their work life, which were addressed by providing a letter for their employer. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Planning : ---------- - Continue Infliximab infusions. - Schedule colonoscopy. - Follow-up appointment in 4 weeks. - Symptomatic management with diet and lifestyle modifications. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)