IBD Visit

IBD History The patient has a history of Crohn's disease, diagnosed in 2015 via colonoscopy. They have previously used medications such as mesalamine and prednisone, but discontinued prednisone due to side effects. The patient underwent intestinal surgery in 2018 and has experienced joint problems as a complication of their disease. Currently, they are taking azathioprine. Subjective Since the last visit, the patient reports mild improvement in symptoms. They have been compliant with their medication regimen, taking azathioprine daily. The patient experiences occasional abdominal pain and reports blood in stool once a week, with an average of 3 bowel movements per day. Objective: Physical examination reveals mild tenderness in the lower abdomen. Recent lab results show elevated inflammatory markers. A colonoscopy performed last month indicated mild inflammation in the ileum. Assessment The patient was diagnosed with Crohn's disease in 2015, affecting the ileum. They have had prior intestinal surgery and are currently on azathioprine. ICD-10 Codes: K50.90 (Crohn's disease, unspecified, without complications) Plan Continue azathioprine. Schedule a follow-up colonoscopy in 6 months. Consider adding a biologic agent if symptoms persist.