Gastroenterology Clinical Letter

Gastroenterologist _Letter prepared by medical scribe, for review and signature by Dr. Anya Sharma._ **Patient Name:** Mrs. Eleanor Vance **Hospital Number:** 45678912 **NHS Number:** 987 654 3210 **Date of Birth:** 01 November 1970 _Referral from Dr. David Green, GP, concerning chronic abdominal pain and recent weight loss._ _Please ensure that the previous diagnosis of Crohn's disease is accurately reflected in this letter, as per our last consultation._ **Face to face follow-up appointment** **Height:** 165 cm **Weight:** 58 kg **BMI:** 21.3 kg/m² **Reason for Referral:** 1. Chronic, waxing and waning abdominal pain, predominantly in the right lower quadrant. 2. Unexplained weight loss of 5 kg over the past 3 months. 3. Intermittent loose stools, sometimes with blood. **Diagnosis:** Crohn's disease, previously diagnosed. **Problem:** Recurrence of Crohn's symptoms with associated weight loss and abdominal pain. **Surgical Details:** 1. Appendicectomy in 1985 (age 15). 2. Ileocolic resection for Crohn's disease in 2010. **Other Details:** 1. Non-smoker, occasional alcohol use. 2. No known drug allergies. 3. Currently experiencing significant fatigue affecting daily activities. **Medications:** Mesalazine 800mg TDS, Azathioprine 50mg daily, Folic acid 5mg weekly. **Allergies:** Penicillin (rash) **Past Medical History:** Hypertension (managed with Amlodipine), GORD (managed with Omeprazole), Crohn's disease (diagnosed 2008, multiple flares). **Family History:** Mother had ulcerative colitis. Father passed away from MI at age 70. No family history of bowel cancer. **Suspected impression:** 1. Crohn's disease flare. 2. Small bowel obstruction (less likely given intermittent nature). **Current symptoms:** 1. Abdominal pain: described as crampy, 6/10 intensity, worse after meals. 2. Bowel habits: 4-5 loose stools per day, sometimes with fresh blood, urgency present. 3. Weight: further 1 kg loss since last review, overall 6 kg lost in 4 months. 4. Energy levels: significantly reduced, impacting daily routine. 5. Appetite: reduced due to pain and nausea. **Advice to GP:** 1. Please continue current medications as prescribed. 2. Monitor full blood count, CRP, and faecal calprotectin in 2 weeks. 3. If symptoms worsen significantly or patient develops fever, please refer back urgently. Mrs. Vance, a 54-year-old female, presented for a follow-up appointment regarding her Crohn's disease. She reports a significant worsening of her symptoms over the past three months, characterised by increasing abdominal pain, frequent loose stools with occasional blood, and further weight loss. Her current medications include Mesalazine and Azathioprine, which she states she is compliant with. She denies any new medications or recent changes to her diet. On examination, there was mild tenderness in the right lower quadrant. Blood tests from two weeks ago showed elevated CRP and a mild anaemia. We discussed the possibility of a Crohn's flare and the need for further investigations to assess disease activity. I have advised a repeat of inflammatory markers and faecal calprotectin. We will consider a colonoscopy and potentially a small bowel MRI depending on these results. I have reassured her about the management plan and advised her to contact the clinic if her symptoms escalate. Yours sincerely