Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Abdominal pain (location, character, frequency, duration)
Diarrhea (frequency, urgency, blood in stool)
Weight loss
Fatigue
Other symptoms (fever, nausea, vomiting, perianal symptoms)
II. History of Present Illness:
Onset and duration of symptoms
Progression of symptoms (worsening, improvement)
Changes in bowel habits
Severity of symptoms (impact on daily life)
Previous flares (hospitalizations, surgeries)
III. Past Medical History:
Diagnosis of Crohn’s disease (age at diagnosis)
Location of Crohn’s disease involvement (small intestine, colon, perianal)
Previous treatments (medications, surgeries)
Comorbid conditions (e.g., anemia, malnutrition)
IV. Social History:
Smoking history (current or past smoker)
Nonsteroidal anti-inflammatory drug (NSAID) use (potential risk factor)
Diet and stress (potential triggers)
V. Medications:
Current medications (anti-inflammatory medications, immunomodulators, biologics)
Over-the-counter medications (including vitamins and supplements)
VI. Physical Exam:
Vital signs (BP, HR, RR, Temp)
Abdominal exam:
Distention, tenderness, masses
Bowel sounds
Perianal exam (if indicated)
VII. Laboratory Studies:
Complete blood count (CBC) – may show anemia
C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) – inflammatory markers (elevated in active disease)
Electrolytes – may be abnormal with dehydration or malnutrition
Fecal calprotectin (stool test) – may indicate inflammation in the gut
VIII. Imaging Studies (consider as appropriate):
Abdominal X-ray (limited role)
Abdominal CT scan (may show bowel wall thickening, strictures, fistulas)
Colonoscopy with terminal ileoscopy (gold standard for diagnosis and disease activity assessment)
MRI enterography (alternative to CT scan for visualization of small bowel)
IX. Assessment:
Disease activity (active vs. inactive) based on clinical presentation, laboratory tests, and imaging studies (if available).
Severity of Crohn’s disease (mild, moderate, severe)
Nutritional status
X. Plan:
Treatment plan depends on disease activity and severity:
Active disease:
Medical therapy to reduce inflammation (anti-inflammatory medications, immunomodulators, biologics)
Dietary modifications (consider exclusion diets)
Nutritional support (oral supplements or enteral nutrition)
Inactive disease:
Maintenance medications to prevent flares
Regular monitoring for recurrence of symptoms
XI. Prognosis:
Discuss the chronic nature of Crohn’s disease and the importance of ongoing management to control symptoms and prevent complications.
Address the patient’s anxieties and concerns related to the disease.
XII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the disease and treatment plan, adherence to medications and diet, potential side effects of medications, and need for emotional support.
XIII. Resources:
Consider providing patient education materials on Crohn’s disease from reputable sources (e.g., Crohn’s and Colitis Foundation, American Gastroenterological Association).