Age: 40.0
Sex: F
Vaccine: COVID19
Symptoms: Frequent bowel movements, Full blood count abnormal, Gastrooesophageal reflux disease, Haematochezia, Haemorrhoids
Clinical narrative: Date of Admission: 9/23/2023   Date of Discharge: 9/28/2023   Issues to be Addressed at Follow-up: Pleasure patient is taking steroid therapy for Crohn's disease as prescribed.  Please ensure patient has scheduled outpatient GI appointment for management of chron's disease Please repeat cbc as wbc was elevated 2/2 steroid use.  Given hx of Crohn's disease please ensure colonoscopy is up-to-date   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/29/2023 to 9/29/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? COVID-19 DISEASE   ? DIVERTICULOSIS   ? INTERNAL HEMORRHOID   ? CROHNS DISEASE OF COLON   ? FHX OF COLON CANCER       Brother died of colon cancer at the age of 40, Another brother died of colon cancer at the age of 60   ? GERD (GASTROESOPHAGEAL REFLUX DISEASE)     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: Patient is a 43 Y female with PMHx of GERD, Migraine, PTSD, MDD, BPD, Crohn's DZ (not on meds), diverticulosis, internal hemm, MVA accident 5/2023 (post concussive syndrome, chronic headaches), admitted 9/23/23 with abdominal pain and hematochezia and increased bowel frequency c/w Crohn's Flare in setting of recent COVID dx 9/18/23. GI consulted. Recommended for IV steroids and transition to oral therapy when able. Outpatient GI follow up.  Patient was discharged on a tapered course of steroid therapy and instructed to follow up with outpatient GI. Last daily of isolation for COVID on 09/28/2023. Patient was provided strict return precautions. Patient voiced understanding.     Vitals:   09/27/23 1800 09/27/23 2352 09/28/23 0400 09/28/23 0729 BP: 124/86 109/68   135/83 Pulse: 83 65   68 Resp: 19 17 16 16 Temp: 98.6 °F (37 °C) 98.3 °F (36.8 °C)   98.6 °F (37 °C) SpO2: 97% 97%   95% Weight:         Height:             General appearance - NAD HEENT: Sclera anicteric.  Neck:No JVD Chest - clear to auscultation Heart - regular rate and rhythm, no murmurs Abdomen - soft, nontender, nondistended, + bowel sounds Extremities - no cyanosis or edema Neuro - A&O x3     Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Crohn's Flare   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. GASTROENTEROLOGY - INITIAL INPATIENT CONSULTATION. GASTROENTEROLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     Note Details  Author (D.O.) File Time 9/28/2023 10:17 AM Author Type PHYSICIAN (D.O.) Status Signed Last Editor (D.O.) Specialty Hospital Medicine Hospital Acct #  Admit Date 9/23/2023  ED to Hosp-Admission (Discharged) on 9/23/2023  ED to Hosp-Admission (Discharged) on 9/23/2023   Detailed Report  Note shared with patient Hospital Problem List   GERD (GASTROESOPHAGEAL REFLUX DISEASE)  CROHNS DISEASE OF COLON  FHX OF COLON CANCER  COVID-19 DISEASE  DIVERTICULOSIS  INTERNAL HEMORRHOID Care Timeline  09/23   Admitted from ED (Observation) 1325 09/25   Admitted 1544 09/28   Discharged 1132  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 9/28/2023)