Physician's Assistant

Refined clerking Thu 28 August 2025 09:46

Last Modified: 221 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Abdominal pain and diarrhoea for 2-3 days

History of Presenting Complaint:
This 48-year-old lady with known ulcerative colitis presented with a 2-3 day Hx of feeling unwell with lower abdominal pain and diarrhoea. She has been experiencing lower abdominal pain radiating to her left leg and back, and bowel frequency of 8-9 times per day with watery, urgent stools without blood or mucus. She feels nauseated but has not vomited. She reports feeling hot and clammy with a documented temperature of 38.5°C.

Past Medical History:
• Ulcerative colitis - diagnosed 2023
• Hospital admission for IV steroids - June 2024
• Hospital admission for IV steroids - January 2025
• Infliximab therapy - commenced January 2025, complicated by very low levels/antibody formation
• Increased infliximab dosing to 10mg/kg - developed infusion reaction June 2025
• Possible reactive arthritis
• Left salpingo-oophorectomy following ovarian torsion

Drug History:
• Mercaptopurine 50mg PO OD
• Cholecalciferol (vitamin D supplementation)

Allergy History:
• Doxycycline

Social History:
Living situation and mobility not documented.
Planning holiday with caravan - first time travelling due to ongoing illness.

On Examination:
General Appearance: Unwell, hot and clammy
Observations: Temperature 38.5°C
Abdominal examination findings not documented in detail, patient reporting significant lower abdominal pain with radiation to back and left leg.

Investigations:
• CRP: 122
• Lipase: 119
• ALP: 142

Impression:
Severe flare of ulcerative colitis
Possible concomitant mercaptopurine-induced pancreatitis

Management Plan:
1. IV steroids for severe UC flare
2. Norfolk ward admission
3. Calcium and vitamin D3 supplementation for duration of steroid therapy
4. Suspend mercaptopurine due to possible pancreatitis
5. IV fluids for dehydration
6. Stool samples for MC&S and C. difficile
7. Abdominal X-ray if abdominal pain persists
8. Ensure pre-immunological screen completed
9. Likely future switch to vedolizumab (pending consultant discussion) given previous infliximab failure

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Refined clerking Thu 28 August 2025 09:46

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