Simple Gastroenterologist Clinic Letter

Patient Name: Mr John Smith Hospital Number: GHS789012 Diagnosis: • Crohn’s Disease – newly diagnosed • Anaemia – iron deficiency Management Plan: • Initiate therapy with Budesonide 9mg once daily for 8 weeks – then review • Iron supplementation with ferrous fumarate 200mg twice daily • Arrange colonoscopy with biopsies – to confirm extent of disease and rule out malignancy • Follow up appointment in 6 weeks – with clinic nurse for review of symptoms and medication adherence • Safety netting discussed – advised to attend A&E if severe abdominal pain or rectal bleeding worsens • Blood tests in 4 weeks – Full Blood Count and inflammatory markers Medications: • Budesonide 9mg – orally – once daily – for Crohn’s flares – for 8 weeks • Ferrous Fumarate 200mg – orally – twice daily – for iron deficiency anaemia – until review • Lansoprazole 30mg – orally – once daily – for reflux – long term I met up with Mr John Smith in the clinic on 1st November 2024. He is a 45-year-old gentleman who was referred by his GP with a 6-month history of intermittent abdominal pain – diarrhoea – and weight loss. He reports having 4-5 loose bowel movements per day – sometimes with blood and mucus. He has lost approximately 5kg over the last 3 months without intentional dieting. He denies any foreign travel or recent antibiotic use. He occasionally experiences joint pains in his knees and ankles. His past medical history includes gastro-oesophageal reflux disease – for which he takes Lansoprazole. He has no known drug allergies. He is a non-smoker and drinks alcohol socially – 10 units per week. There is a family history of inflammatory bowel disease – his mother has Ulcerative Colitis. On examination – Mr Smith appeared well but slightly pale. Abdominal examination revealed mild tenderness in the right lower quadrant – with no guarding or rebound tenderness. There was no hepatosplenomegaly. Rectal examination was unremarkable. His vital signs were stable. Blood tests taken prior to the clinic visit showed a haemoglobin of 9.8 g/dL – MCV 78 fL – C-reactive protein 35 mg/L – and faecal calprotectin of 850 µg/g. His symptoms – elevated inflammatory markers – and high faecal calprotectin are highly suggestive of inflammatory bowel disease – specifically Crohn’s Disease. The anaemia is likely secondary to chronic blood loss and inflammation. We have discussed the provisional diagnosis and the need for further investigations to confirm the diagnosis and assess disease extent. We discussed the treatment options – including corticosteroids to induce remission and subsequent maintenance therapies. Mr Smith was keen to start treatment to alleviate his symptoms. We also counselled him on dietary modifications and the importance of hydration. We provided him with information leaflets about Crohn’s Disease and the local support groups available. In summary therefore – Mr Smith has symptoms and investigations consistent with active Crohn’s Disease. He has commenced Budesonide and iron supplementation. He is booked for a colonoscopy and a follow-up appointment with the clinic nurse for ongoing management and education. Many thanks.