Gastroenterology Consultation
REASON FOR CONSULT:
Patient presents for evaluation of worsening abdominal pain and bloody stools.
HISTORY OF PRESENT ILLNESS:
Patient is a 35-year-old male referred by Dr. Emily Carter. He reports a two-month history of increasing abdominal cramping, particularly after meals, accompanied by frequent bowel movements, often with blood and mucus. He also reports fatigue and unintentional weight loss of 5kg over the past month. He denies fever, chills, or night sweats. The patient reports that the symptoms started gradually and have progressively worsened. He has tried over-the-counter medications for symptomatic relief, but they have provided minimal benefit.
INFLAMMATORY BOWEL DISEASE HISTORY:
1. Diagnosis: Ulcerative colitis, diagnosed in 2018.
2. Current Therapy: Mesalamine 4.8g daily.
3. Prior therapy:
* Prednisone - effective initially, but with significant side effects and loss of efficacy.
* Azathioprine - caused nausea and elevated liver enzymes, discontinued.
4. Most Recent Colonoscopy:
* Performed in January 2024.
* Showed extensive inflammation in the sigmoid colon and rectum.
* Biopsies confirmed active ulcerative colitis.
5. Fecal Calprotectin: Elevated at 1200 mcg/g.
6. Surgical History: None.
7. Extraintestinal Manifestations: None reported.
PAST MEDICAL HISTORY:
1. Seasonal allergies.
MEDICATIONS:
1. Mesalamine 4.8g daily.
2. Loratadine 10mg daily.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
Patient is a software engineer and lives in London. He is married with two children. He denies tobacco use and drinks alcohol socially (2-3 units per week).
FAMILY HISTORY:
Mother has a history of rheumatoid arthritis. Father is healthy. No family history of inflammatory bowel disease.
PHYSICAL EXAM:
- Abdomen: Mildly tender to palpation in the left lower quadrant. No guarding or rebound tenderness. Bowel sounds are normoactive.
INVESTIGATIONS:
- Laboratory results: Complete blood count (CBC) shows mild anemia (Hb 11.5 g/dL). Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
- Colonoscopy results: See above.
ASSESSMENT AND PLAN:
1. Ulcerative Colitis
Assessment: Active ulcerative colitis with moderate disease severity based on clinical symptoms, endoscopic findings, and elevated inflammatory markers. The patient is not responding adequately to current therapy.
Differential diagnosis: Rule out infectious colitis, ischemic colitis, and medication-induced colitis.
- Investigations planned: Repeat colonoscopy with biopsies in 3 months to assess response to treatment.
- Medical treatment planned: Initiate Infliximab 5mg/kg IV every 8 weeks. Prednisone 40mg daily for 2 weeks, then taper.
- Lifestyle modifications: Advise the patient to follow a low-residue diet and avoid foods that exacerbate symptoms. Encourage adequate hydration and stress management techniques.
- Follow-up appointments: Schedule follow-up appointment in 2 weeks to assess tolerance to Infliximab and prednisone. Follow-up colonoscopy in 3 months.
- Relevant referrals: Refer to a registered dietitian for dietary counseling.
[2. Additional Gastrointestinal Issues or Conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Additional Notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Patient education on the diagnosed condition, including explanation of the condition, potential complications, and the importance of treatment adherence: The patient was educated on the nature of ulcerative colitis, its chronic nature, and the importance of adhering to the treatment plan. The patient was informed about the potential complications, including the risk of colon cancer, and the need for regular colonoscopic surveillance.
- Instructions for symptom monitoring and when to seek immediate care: Instructed the patient to seek immediate medical attention if he develops severe abdominal pain, high fever, or significant rectal bleeding.
- Any specific patient or family concerns addressed during the consultation: Addressed the patient's concerns about the impact of the disease on his quality of life and the potential side effects of the medications.
