Physician's Assistant

-3

Refined clerking Thu 20 November 2025 22:50

Last Modified: 137 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Ulcerative colitis flare

History of Presenting Complaint:
Patient with known ulcerative colitis admitted with worsening symptoms following failed infliximab infusion. Had been receiving infliximab treatment but developed severe allergic reaction during recent infusion with facial swelling, throat tightness, and shortness of breath requiring emergency treatment. Since discontinuing infliximab and reducing prednisolone dose, symptoms have progressively worsened over past 2 days.

Currently experiencing increased bowel frequency (7 times daily) with loose, watery stools but no blood. Experiencing lower abdominal pain described as similar to previous flares but less severe. Reports hot flushes and night sweats since hospital admission. Also experiencing frequent nosebleeds and facial lesion with purulent discharge for past week.

Past Medical History:
• Ulcerative colitis - recent diagnosis with aggressive disease pattern
• Anaemia secondary to IBD
• Infliximab allergy - severe reaction with facial swelling and respiratory symptoms

Drug History:
• Prednisolone 35mg PO OD (reducing - due to decrease to 30mg tomorrow)
• Omeprazole 20mg PO BD
• Mesalazine tablets PO
• Cholecalciferol (Vitamin D3)
• Topical treatment for perianal irritation (improving)

Recently Stopped Medications:
• Infliximab - stopped due to severe allergic reaction

Allergy History:
• Infliximab - severe allergic reaction (facial swelling, throat tightness, shortness of breath)

Social History:
Living situation not specified
Mobility independent
No carers mentioned
Occupation not specified
Smoking status not mentioned
Alcohol history not mentioned
Functional Status: Disease impacting quality of life with frequent hospital admissions

On Examination:
General Appearance: Alert, appears well but concerned about recurrent symptoms
Observations: Temperature 37.2°C, other observations not specified
• Abdomen: Tender in lower abdomen, particularly left lower quadrant. No peritonism
• Cardiovascular: Not examined
• Respiratory: Not examined
• Neurological: Not examined
• Other: Facial lesion on cheek with small punctum and underlying induration, evidence of purulent discharge. No other skin lesions noted

Investigations:
• CRP: 136 mg/L (elevated, previously 100+ on admission, had reduced to 80 but now rising again)
• Temperature: 37.2°C
• COVID test: Negative

Impression:
Ulcerative colitis flare following discontinuation of infliximab due to severe allergic reaction
Differential Diagnoses: Possible underlying infection given raised inflammatory markers
Secondary issues: Steroid side effects including facial skin infection, nosebleeds, and constitutional symptoms

Management Plan:
1. Admit for IV steroid therapy to induce remission quickly
2. Monitor inflammatory markers and clinical response to treatment
3. Continue PPI cover while on high-dose steroids
4. Dermatology review of facial lesion if not improving
5. Discuss alternative biologic therapies with IBD team for December 8th appointment
6. Patient education regarding realistic timeframes for alternative treatments
7. Gastroenterology bed
8. Escalation plan to be discussed - likely appropriate for all active treatments given young age and new diagnosis

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Refined clerking Thu 20 November 2025 22:50

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