CROHN DISEASE

History of present illness (HPI) :

Andy Lim is 32 year old woman with a 14 year history of crohn disease who presents
with a three – day history of diarrhea and steady abdominal pain. She has been referred
by her PCP to the GI clinic. The clinical course of her disease has included obstruction
due to small intestine stricture and chronic steroid dependency with disease relapse
attempting to taper steroids. Endocrine reveal that she has developed adrenal
insufficiency as a result of steroid use and a DEXA scan has demonstrated significant
demineralization of bone.

Past Surgical History (PSH)

• Portion of small bowel resected 5 years ago (obstruction from scarring and stricture)
• Ovarian cyst drained, age 18
• Appendectomy, age 13

Past Medical History (PMH)

• Crohn disease diagnosed 14 years ago (weight loss, severe diarrhea with multiple
bowel movements, abdominal pain, dehydration)
• Major depression

Family History (FH)

No family Hx of IBD

History of Medication
Prednisone, 40 mg po QD
Trazodone, 100 mg po BID
Cyanocobalamin, 250 μg IM Q month
Genogram

Legend:
A&W : Alive and well
N/A: Not applicable

Female patient Female

Male

Andy Lim, a 32
year old with Name: N/A
Crohn Disease

Mother Father

A&W A&W

Daughter Daughter