The patient is a 34-year-old female, Ms. Sarah Jenkins, attending a follow-up consultation in the Gastroenterology clinic via video call. She was referred by her GP for ongoing management of her Inflammatory Bowel Disease.
IBD PROFILE
Diagnosis
* Ulcerative Colitis, pancolitis, diagnosed in October 2018 by Dr. Eleanor Vance at St. Jude's Hospital.
Summary of course
* In October 2018, diagnosed with Ulcerative Colitis after presenting with bloody diarrhoea and abdominal pain. Initial treatment with oral Mesalazine 2.4g daily. FCP result was 1200 µg/g.
* In April 2019, experienced a moderate flare, requiring a course of oral Prednisolone 40mg tapering over 8 weeks. Mesalazine dose increased to 4.8g daily.
* In July 2020, developed steroid dependency. Commenced on Azathioprine 100mg daily. FCP result 450 µg/g.
* In January 2021, Azathioprine discontinued due to persistent abnormal LFTs. Started on Vedolizumab 300mg IV at weeks 0, 2, 6, then every 8 weeks. Vedolizumab trough level 28 µg/mL.
* In March 2022, remained in clinical remission. FCP result 75 µg/g.
* In November 2023, reported mild increase in stool frequency, no blood. Vedolizumab trough level 25 µg/mL. FCP result 150 µg/g.
Current Treatments:
* Vedolizumab 300mg IV every 8 weeks (last dose 15 October 2024)
* Mesalazine 4.8g daily (oral)
Preventative
* Vaccinations:
* Influenza vaccine: October 2024
* Pneumococcal vaccine: September 2022
* Tetanus/Diphtheria/Pertussis: April 2021
* Infection screening:
* HBV surface antigen: Negative (July 2020)
* HCV antibody: Negative (July 2020)
* TB Quantiferon Gold: Negative (July 2020)
* CXR: Clear (July 2020)
* Nutrition:
* Follows a low FODMAP diet, avoiding lactose and gluten due to previous bloating. Reports good adherence and finds it helps with symptoms.
Ms. Jenkins reports stable bowel movements, typically 1-2 soft stools per day, without blood or urgency. She denies any abdominal pain or tenesmus. Her weight has remained stable at 65 kg over the past six months.
INVESTIGATIONS
* HGB: 13.2 g/dL (28 October 2024)
* WBC: 7.8 x10^9/L (28 October 2024)
* Neutrophils: 4.5 x10^9/L (28 October 2024)
* Lymphocytes: 2.5 x10^9/L (28 October 2024)
* PLT: 280 x10^9/L (28 October 2024)
* Ferritin: 85 ng/mL (28 October 2024)
* CRP: 2 mg/L (28 October 2024)
* Creatinine: 70 µmol/L (28 October 2024)
* Vit. B12: 350 pg/mL (28 October 2024)
* ALT: 25 U/L (28 October 2024)
* AST: 20 U/L (28 October 2024)
* ALP: 80 U/L (28 October 2024)
* Albumin: 42 g/L (28 October 2024)
* 6-TG: Not applicable (patient on Vedolizumab)
* 6-MMP: Not applicable (patient on Vedolizumab)
* FCP: 110 µg/g (28 October 2024)
ASSESSMENT AND PLAN
* The patient is a 34-year-old female with pancolitic Ulcerative Colitis, currently in clinical and biochemical remission on Vedolizumab and Mesalazine.
Problem 1. Ulcerative Colitis, pancolitis. Ms. Jenkins remains in good clinical and biochemical remission on current therapy. Her FCP remains low and inflammatory markers are within normal limits. Vedolizumab treatment to continue as per current regimen.
* Faecal Calprotectin: Annually (next due October 2025)
Problem 2. CRC screening. Given her diagnosis of pancolitic Ulcerative Colitis for 6 years, regular colorectal cancer surveillance is recommended. Patient informed of recommendations.
* Colonoscopy: Every 2 years (next due November 2025)
Problem 3. Nutritional considerations. Ms. Jenkins is managing well on a low FODMAP diet. No signs of nutritional deficiencies currently. She will continue with her current dietary approach.
Problem 4. Psychological well-being. Patient reports good mental health, no anxiety or depression related to her IBD. Continues to engage with a local support group.
Next consultation scheduled in 6 months for routine follow-up, to be conducted via video call, approximately 1 May 2025.
[patient demographics, reason for consultation, and relevant background information including mode of consultation and clinic type] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
IBD PROFILE
Diagnosis
• [IBD diagnosis, classification, and onset details, including diagnosing physician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
Summary of course
• [chronological summary of the patient's IBD history, including initial diagnosis, treatment course, flares, complications, and significant events, including all relevant dates, medications, and physician names mentioned. Include all biological drug levels and all fecal calprotectin (FCP) results.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list using full sentences, starting each item with the date using the format "In [month] [year]".)
Current Treatments:
• [current IBD medications and their dosages/frequencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
Preventative
• Vaccinations: [list of vaccinations with dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
• Infection screening: [results of infection screenings for HBV, HCV, TB, and CXR status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
• Nutrition: [details on patient's diet and any restrictions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
[current symptoms, bowel movements, presence of pain, and weight stability] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
INVESTIGATIONS
• [laboratory investigation results including HGB, WBC, Neutrophils, Lymphocytes, PLT, Ferritin, CRP, Creatinine, Vit. B12, ALT, AST, ALP, Albumin, 6-TG, 6-MMP, and FCP, with dates for each entry] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
ASSESSMENT AND PLAN
• [patient's current IBD status, including age, gender, diagnosis, classification, and symptomatic state] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
Problem 1. [details regarding Ulcerative colitis or Crohn's disease as a problem, including investigations arranged and any IBD medical changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
• [specific investigations scheduled for Ulcerative colitis or Crohn's disease, with frequencies or dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.)
Problem 2. [details regarding CRC screening as a problem, including screening recommendations and next screening date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Problem 3. [details regarding other relevant gastrointestinal problems including possible causes and current management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Problem 4. [details regarding relevant gastrointestinal problems as a problem, including current status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[details regarding scheduling of next consultation, including time frame and mode of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)