Inflammatory Bowel Disease New Patient

IBD New Patient: REASON FOR VISIT: Initial Consultation for abdominal pain REFERRING PHYSICIAN: Dr. Sarah Johnson ATTENDING PHYSICIAN: Dr. Thomas Kelly, MD CHIEF CONCERN: Persistent abdominal pain and diarrhea HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old male who presents with a 6-month history of intermittent abdominal pain and diarrhea. Symptoms began gradually and have been worsening over the past two months. The pain is crampy, located in the lower abdomen, and is often relieved by bowel movements. The patient reports 4-5 loose stools per day, occasionally with blood and mucus. He has experienced a 5 kg weight loss over the past three months. No significant relief with over-the-counter antidiarrheal medications. The patient denies nausea, vomiting, or fever. He reports occasional joint pain and redness in the eyes. REVIEW OF SYSTEMS: - Denies fevers/sweats/chills - Reports weight loss - Denies oral ulcers PROBLEM LIST: - Abdominal pain - Diarrhea - Weight loss CURRENT MEDICATIONS: - Loperamide 2 mg as needed - Multivitamin daily ALLERGIES: - Penicillin (rash) PAST MEDICAL HISTORY: - Irritable Bowel Syndrome (diagnosed 2019) PAST SURGICAL HISTORY: - Appendectomy (2010) FAMILY HISTORY: - Father with Crohn's disease SOCIAL HISTORY: - Non-smoker - Occasional alcohol use - Works as a software engineer VITALS: - BP: 120/80 mmHg - Pulse: 78 bpm - Height: 180 cm - Weight: 75 kg - BMI: 23.1 PHYSICAL EXAMINATION - General: Well-nourished, in no acute distress - HEENT: Conjunctival injection noted - CV: Normal heart sounds, no murmurs - Respiratory: Clear to auscultation bilaterally - Abdomen: Mild tenderness in the lower quadrants, no rebound or guarding - Extremities: No edema, full range of motion LABS: - Elevated C-reactive protein - Low hemoglobin ASSESSMENT/PLAN: 35 y.o. male with a history of IBS, presenting with symptoms suggestive of inflammatory bowel disease. 1. Suspected Inflammatory Bowel Disease - History of abdominal pain, diarrhea, and weight loss with family history of Crohn's disease. - Initiating maintenance therapy with biologics. - Plan for follow-up colonoscopy and lab tests in 4 weeks. Dr. Thomas Kelly, MD