The patient, Mrs. Eleanor Vance, is a 48-year-old female attending this gastroenterology consultation via telemedicine. She is being followed for management of her Inflammatory Bowel Disease.
IBD PROFILE
Diagnosis
* Ulcerative Colitis, pancolitis, diagnosed in October 2010. Classified as moderate to severe.
Summary of course
* In October 2010, diagnosed with Ulcerative Colitis after presenting with bloody diarrhoea and abdominal pain. Initial treatment included high-dose oral corticosteroids and mesalazine.
* In January 2011, achieved remission with mesalazine 2.4g daily.
* In April 2015, experienced a flare requiring a course of budesonide.
* In November 2018, another flare-up led to the initiation of Infliximab therapy. Infliximab level on 12 June 2024 was 12.5 ug/mL (therapeutic range 3-7 ug/mL). Fecal calprotectin (FCP) on 12 June 2024 was 78 mcg/g (normal < 50 mcg/g).
* In March 2023, complicated by a perianal abscess which was surgically drained.
Current Treatments:
* Infliximab 5 mg/kg IV every 8 weeks
* Mesalazine 2.4g orally daily
Preventative
* Vaccinations:
* Influenza vaccine: October 2023
* Pneumococcal vaccine: September 2022
* Tetanus/Diphtheria/Pertussis: March 2021
* Hepatitis B vaccine series: Completed August 2019
* Infection screening:
* HBV: Negative (August 2019)
* HCV: Negative (August 2019)
* TB: Negative PPD test (September 2019), CXR clear (September 2019)
* Nutrition:
* Follows a low-FODMAP diet due to persistent bloating. Avoids dairy and gluten by choice.
Mrs. Vance reports intermittent, mild abdominal discomfort, primarily in the left lower quadrant, occurring 2-3 times per week. She describes her bowel movements as 3-4 times per day, often loose, with occasional urgency but no frank blood. Her weight has been stable at 65kg for the past six months, with no reported loss of appetite.
FAMILY HISTORY
* Mother had polyps removed during routine colonoscopy at age 60.
* Paternal aunt diagnosed with Crohn's disease at age 55.
PAST HISTORY
* Appendectomy: April 2005
* Cholecystectomy: November 2015
OTHER MEDICATIONS
* Sertraline 50mg orally daily for anxiety.
* Vitamin D 1000 IU orally daily.
ALLERGIES
* Penicillin: Hives
* Codeine: Nausea and vomiting
SOCIAL HISTORY
Mrs. Vance is married with two children, aged 18 and 22. She is a primary school teacher, currently working full-time. She denies current smoking but has a past history of social smoking (quit 5 years ago). She consumes alcohol occasionally, approximately 1-2 units per week. She denies marijuana use.
PHYSICAL EXAMINATION
Physical examination was deferred due to the telemedicine nature of the consultation. Patient reports no new or concerning physical symptoms requiring immediate in-person assessment.
INVESTIGATIONS
* HGB: 12.8 g/dL (12 June 2024)
* WBC: 7.2 x 10^9/L (12 June 2024)
* Neutrophils: 4.5 x 10^9/L (12 June 2024)
* Lymphocytes: 2.0 x 10^9/L (12 June 2024)
* PLT: 280 x 10^9/L (12 June 2024)
* Ferritin: 85 ng/mL (12 June 2024)
* CRP: 4 mg/L (12 June 2024)
* Creatinine: 68 umol/L (12 June 2024)
* Vit. B12: 350 pg/mL (12 June 2024)
* ALT: 25 U/L (12 June 2024)
* AST: 20 U/L (12 June 2024)
* ALP: 70 U/L (12 June 2024)
* Albumin: 42 g/L (12 June 2024)
* 6-TG: 250 pmol/8x10^8 RBC (28 July 2024)
* 6-MMP: <20 pmol/8x10^8 RBC (28 July 2024)
* FCP: 78 mcg/g (12 June 2024)
ASSESSMENT AND PLAN
* Mrs. Eleanor Vance, a 48-year-old female, with active Ulcerative Colitis, pancolitis, experiencing mild symptomatic activity despite high Infliximab levels.
Problem 1. Ulcerative Colitis (pancolitis): The patient is experiencing ongoing mild abdominal discomfort and loose bowel movements. Despite high Infliximab levels, her FCP remains mildly elevated, suggesting ongoing inflammation. We will consider optimising medical therapy. Discussion with patient regarding escalating therapy options, including ustekinumab or vedolizumab, if symptoms do not improve. We will also monitor for infectious causes of symptoms.
* Repeat Fecal Calprotectin: In 3 months (February 2025).
* Therapeutic Drug Monitoring (TDM) for Infliximab and anti-drug antibodies: Not immediately indicated given current high level, but will reassess if symptoms worsen.
Problem 2. CRC screening: Patient with pancolitis for 14 years. Due for surveillance colonoscopy.
Problem 3. Persistent bloating/GI discomfort: Patient is following a low-FODMAP diet which provides some relief. Continue dietary modifications. Consider a referral to a dietitian for further guidance.
Problem 4. Anxiety: Patient is well-controlled on Sertraline. Continue current medication.
Next consultation scheduled in 3 months (February 2025) via telemedicine to review FCP results and discuss potential therapy escalation.
