What should be included in the physical exam for a 50-year-old male patient with Crohn's disease (in remission on weekly Humira (adalimumab) since 2018), hypertension, health anxiety, benign prostatic hyperplasia (BPH), chronic prostatitis, and chronic pelvic pain at 6-month check-ups?

From the Guidelines

The physical exam for a 50-year-old male with multiple chronic conditions, including Crohn's disease, hypertension, health anxiety, BPH, chronic prostatitis, and chronic pelvic pain, should be comprehensive and targeted, including vital signs, abdominal examination, digital rectal examination, lymphadenopathy and skin lesion assessment, musculoskeletal examination, infection evaluation, and mental health screening, every 6 months. The patient's complex medical history necessitates a thorough and regular assessment to monitor disease progression, medication side effects, and early detection of complications. Given the patient's Crohn's disease status, the physical exam should focus on assessing for signs of disease activity, such as abdominal tenderness, masses, and bowel sounds, as recommended by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1. The digital rectal examination is crucial for evaluating prostate size, tenderness, and nodules related to BPH and chronic prostatitis, as suggested by the AUA guideline on management of benign prostatic hyperplasia 1. Regular laboratory work, including complete blood count, liver function tests, inflammatory markers like C-reactive protein and fecal calprotectin, and PSA levels for prostate monitoring, should complement the physical exam, as recommended by the AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease 1. The most recent and highest quality study, the 2021 AGA clinical practice guidelines, supports the use of a comprehensive and targeted approach to managing patients with multiple chronic conditions, including Crohn's disease, and emphasizes the importance of regular monitoring and timely intervention to prevent complications and improve quality of life 1. The patient's health anxiety should also be addressed through a brief neurological assessment and mental health screening, as part of a comprehensive approach to managing his chronic conditions. Overall, a systematic evaluation every six months, incorporating physical exam, laboratory work, and mental health screening, is essential for ensuring continuity of care and timely intervention for this complex patient with multiple chronic conditions.

From the Research

Monitoring of Chronic Conditions

The patient has multiple chronic conditions, including Crohn's disease, hypertension, health anxiety, benign prostatic hyperplasia (BPH), chronic prostatitis, and chronic pelvic pain. To monitor these conditions effectively, the following should be included in the physical exam at 6-month check-ups:

• Blood pressure check to monitor hypertension
• Abdominal exam to assess for any tenderness or masses, which can be indicative of Crohn's disease or other gastrointestinal issues
• Digital rectal exam (DRE) to assess the prostate for any abnormalities, which can be indicative of BPH or prostatitis
• Urinalysis to check for any urinary tract infections or other abnormalities
• Assessment of mental health, including anxiety and depression

Physical Exam Components

The physical exam should include the following components:

• Vital signs: blood pressure, heart rate, respiratory rate, and temperature
• Abdominal exam: assess for tenderness, masses, or other abnormalities
• Genitourinary exam: DRE, assess for any prostate abnormalities
• Musculoskeletal exam: assess for any pain or tenderness in the pelvic area
• Mental health assessment: assess for anxiety, depression, or other mental health concerns

Frequency of Monitoring

The patient should be monitored every 6 months, with the following tests and exams:

• Blood work: complete blood count (CBC), basic metabolic panel (BMP), liver function tests (LFTs), and inflammatory markers (such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)) to monitor Crohn's disease and other conditions 2
• Urinalysis: to check for any urinary tract infections or other abnormalities
• Prostate-specific antigen (PSA) test: to monitor for any prostate abnormalities
• DRE: to assess the prostate for any abnormalities

Management of Chronic Conditions

The management of the patient's chronic conditions should include:

• Medication management: the patient is currently taking Humira for Crohn's disease, and may need to continue or adjust this medication based on disease activity 2
• Lifestyle modifications: the patient should be encouraged to make healthy lifestyle choices, such as a balanced diet, regular exercise, and stress management
• Monitoring for complications: the patient should be monitored for any complications of their chronic conditions, such as bowel obstruction or urinary retention

Evidence-Based Practice

The management of the patient's chronic conditions should be based on evidence-based practice, including:

• The use of 5-alpha reductase inhibitors for the treatment of BPH 3
• The use of adalimumab for the treatment of Crohn's disease 2, 4
• The use of pharmacological interventions for the treatment of chronic prostatitis/chronic pelvic pain syndrome 5