Physician's Assistant

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Acute severe ulcerative colitis flare

History of Presenting Complaint:
21-year-old lady known to gastroenterology with ulcerative colitis diagnosed in April 2025, presenting with ongoing flare symptoms. She reported increased bowel frequency with intermittent diarrhoea and blood in the stool, with abdominal pain, predominantly off and on, and symptoms worsening again from around June 2025. She also described systemic flare symptoms including significant fatigue and functional limitation due to joint pain and arthritis. She reported intermittent pain on passing urine over the preceding few weeks. She reported night sweats and sweats when cold. She described substantial weight loss, losing approximately 5 stone over the preceding year.

She has had multiple recent health-care encounters for flares and extraintestinal manifestations. In June 2025 she had erythema nodosum on a background of hidradenitis suppurativa. A subsequent admission in June 2025 for an ulcerative colitis flare was treated with steroids, then switched to oral Pentasa with symptomatic improvement. Despite this, inflammatory markers increased in the community and she required further short courses of steroids since July 2025.

Collateral history: Father had a colectomy in 2025. Paternal uncle has Crohn’s disease. She is followed by rheumatology and dermatology for fibromyalgia and ibd-related arthritis and hidradenitis suppurativa.

Past Medical History:
• Ulcerative colitis (April 2025)
• Hidradenitis suppurativa
• Erythema nodosum (June 2025)
• Iron deficiency anaemia
• IBD-related arthritis
• Fibromyalgia

Drug History:
• Pentasa 4g granules PO (dose as prescribed, BD/OD not specified)
• Prednisolone 40mg PO OD, reducing by 5mg each week (1 week into course at time of admission)

Allergy History:
NKDA

Social History:
Mobility: significantly limited by pain and arthritis.
Carers: requires significant carer support.

On Examination:
General Appearance: very unwell and distressed.
Observations: Temp 37.5°C, HR 113 bpm, RR 15/min, BP 121/73 mmHg, SpO2 96%.
• Abdomen: soft, non-specified tenderness.
• Cardiovascular: tachycardia.
• Respiratory: chest examination performed; no specific abnormality recorded.
• Other: swollen knees and feet reported; erythematous nodules consistent with erythema nodosum reported.

Investigations:
• Full blood count (taken 17/03/2026): Hb 84 g/L (from 123), platelets 801 (elevated), WBC 13.7 with neutrophils 11.22.
• Indices (taken 17/03/2026): microcytic anaemia with MCV 78.3 and raised RDW 16.3.
• Renal function (taken 17/03/2026): creatinine 65 µmol/L (AKI stage 1, up from 44 baseline).
• Electrolytes (taken 17/03/2026): sodium 139, potassium 4.5.
• Liver function tests (taken 17/03/2026): albumin 28; remaining LFTs and biliary values without specified abnormality, bilirubin <3.
• Inflammatory marker (taken 17/03/2026): CRP 68, historically chronically raised since April 2025 and up to 227 in September 2025.
• Bone profile/TFT: phosphate normal; TSH normal.
• Urea (taken 17/03/2026): 2.6.
• Chest X-ray (13/02, pre-biologic screening): normal.
• Pre-biologic screening (September 2025): no blood-borne viruses; TB Spot negative.

Impression:
Acute severe ulcerative colitis flare with evidence of systemic involvement, including hypoalbuminaemia, inflammatory anaemia, raised CRP, AKI stage 1, and extraintestinal involvement including erythema nodosum and hidradenitis suppurativa.

Management Plan:
1. Escalation and immediate monitoring given systemic involvement and tachycardia.
2. Obtain further investigations including repeat blood tests to assess trends in inflammatory markers and anaemia/renal function.
3. Repeat chest X-ray and obtain abdominal imaging to exclude complications prior to starting biologic therapy.
4. Plan to commence infliximab once baseline investigations completed and confirmed suitable; pre-biologic screening previously negative.
5. Consider short-course steroids to control inflammation and symptoms, with regimen already in place (prednisolone taper).
6. Iron replacement: defer IV iron/infusion until after initial infliximab dose and inflammatory markers improve due to infection risk in the setting of active severe inflammation.
7. Arrange admission/transfer to appropriate unit for infliximab administration (Allerton unit described as the appropriate site within the hospital for infliximab delivery).
8. Ongoing management of hidradenitis suppurativa and IBD-related arthritis with relevant specialties (rheumatology/dermatology input already in place).
9. Patient support and counselling regarding treatment plan and expected symptom improvement; explain rationale for delaying iron during active inflammation and for completing pre-biologic safety checks.

Summary:

Investigations:

Refined clerking Wed 18 March 2026 19:55

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