Crohn's Disease: A Case Study
This is a case of a 62-year-old male claimant who is diagnosed with Crohn's disease, type 2 diabetes mellitus, essential hypertension, and overweight.
The claimant works as a Design Engineer. The physical demands of his job includes occasional lifting/carrying from 10 up to 20 pounds, occasional reaching upward and downward, occasional standing and walking, and frequent sitting.
An attending physician statement dated 02/02/2015 indicated that the claimant has class 3 physical impairment with moderate limitation of functional capacity and capable of clerical/administrative activity. He was noted to be limited by bowel movements and needed unrestricted access to bathroom.
Laboratory results dated 05/04/2015 showed elevated glucose at 310, …show more content…
Colonoscopy dated 04/29/2015 showed persistent severe colitis consistent with Crohn's disease with some improvement. The rectosigmoid colon had patchy erythema and erosions rather than pancolitis, however, in the descending colon and transverse colon, there were deep punched out ulcers with irregular shapes which was deeper than what had been seen before. There was a denucled mucosa and narrowing in the proximal transverse colon and hepatic …show more content…
On 08/20/2017, the claimant had Crohn's colitis and had Remicade infusion.
On 10/23/2015, the claimant had complaints of itching on his back and some on his upper arms. His back had redness and whelps. He had Remicade infusion during visit.
On 12/18/2015, the claimant presented for Remicade infusion. He had itching and rash at the last infusion. His BMI was 27.99 with a blood pressure was 128/81.
On 02/15/2016, the claimant presented for Remicade infusion. He had severe Crohn's colitis with initial difficult to control bleeding, diarrhea, weight loss, and dehydration. He had upper endoscopy after his severe colitis on 04/2015 and had evidence of chronic active colitis but no stricture. He estimated having 4-5 bowel movements a day but they were unexpected. He noted some urgency but not as much problematic incontinence.
Laboratory results dated 02/16/2016 showed elevated glucose at 156.
On 04/12/2016, the claimant had Remicade
The claimant works as a Design Engineer. The physical demands of his job includes occasional lifting/carrying from 10 up to 20 pounds, occasional reaching upward and downward, occasional standing and walking, and frequent sitting.
An attending physician statement dated 02/02/2015 indicated that the claimant has class 3 physical impairment with moderate limitation of functional capacity and capable of clerical/administrative activity. He was noted to be limited by bowel movements and needed unrestricted access to bathroom.
Laboratory results dated 05/04/2015 showed elevated glucose at 310, …show more content…
Colonoscopy dated 04/29/2015 showed persistent severe colitis consistent with Crohn's disease with some improvement. The rectosigmoid colon had patchy erythema and erosions rather than pancolitis, however, in the descending colon and transverse colon, there were deep punched out ulcers with irregular shapes which was deeper than what had been seen before. There was a denucled mucosa and narrowing in the proximal transverse colon and hepatic …show more content…
On 08/20/2017, the claimant had Crohn's colitis and had Remicade infusion.
On 10/23/2015, the claimant had complaints of itching on his back and some on his upper arms. His back had redness and whelps. He had Remicade infusion during visit.
On 12/18/2015, the claimant presented for Remicade infusion. He had itching and rash at the last infusion. His BMI was 27.99 with a blood pressure was 128/81.
On 02/15/2016, the claimant presented for Remicade infusion. He had severe Crohn's colitis with initial difficult to control bleeding, diarrhea, weight loss, and dehydration. He had upper endoscopy after his severe colitis on 04/2015 and had evidence of chronic active colitis but no stricture. He estimated having 4-5 bowel movements a day but they were unexpected. He noted some urgency but not as much problematic incontinence.
Laboratory results dated 02/16/2016 showed elevated glucose at 156.
On 04/12/2016, the claimant had Remicade