by Lenore Jarvis, Children’s National Health System

14 yo with Crohn’s disease, presenting with concerns for possible flare. She has had decreased PO due to pain, nausea and diarrhea and is lightheaded and weak. The patient has not improved with steroids as an outpatient and now has had 15 lbs weight loss in 3 weeks. Her last flare a few months ago required admission. Current flare started one month ago with athralgias and generalized aches/pains with fever. Progressed to belly pain, decreased appetite and bloody diarrhea. She started 40mg daily Prenisolone with resolution of fevers and arthralagias but has had persistent poor PO. Still drinking water with good UOP. Denies current abdominal pain. Stools several times a day that are loose, with bright-red blood.

Maintained on Pentasa 3,000 div BID. Has never received remicade.

Vital Signs
T 37.0, HR 113, RR 20, BP 126/89, sat 98% RA, 43.8 kg
General: Alert. Appropriate for age. Visibly uncomfortable.
Skin: Warm. dry. intact. no rashes.
Eye: Normal conjunctiva
Cardiovascular: Tachycardia, regular rhythm. No murmur. No gallop. Normal peripheral perfusion. Extremity pulses equal.
Respiratory: Lungs are clear to auscultation. respirations are non-labored. breath sounds are equal.
Gastrointestinal: Soft. Non distended. Diffusely tender to palpation. Pain worse in LLQ. Decreased BS. No gross blood, tags, or fissures on rectal exam.
Musculoskeletal: No tenderness. no swelling. no deformity. moves all extremities.
Neurological: Alert. No focal neurological deficit observed. CN II-XII intact.

Labs significant for WBC 19.9, Hgb/Hct 9.2/28.2, plt 485; ESR 33, CRP 2.82; CMP with tot ptn 5.8, albumin 1.9

Bedside ultrasound of abdomen shows mild amount of free fluid and bowel wall thickening consistent with IBD flare.

Admitted to GI for a Crohn’s flare, unresponsive to PO steroids where she was evaluated for infectious colitis and initiated on IV steroids and Remicade. She was discharged home one week later after her first Remicade infusion.