Physician's Assistant

Refined clerking Wed 18 March 2026 20:00

Last Modified: 19 days ago

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Presenting Complaint:
Acute flare of ulcerative colitis

History of Presenting Complaint:
21-year-old lady with known ulcerative colitis, diagnosed in April 2025, reviewed in gastroenterology clinic with worsening symptoms and systemic inflammation. She has had two admissions in June 2025, one with a flare of erythema nodosum on a background of hidradenitis suppurativa, and another with a flare of ulcerative colitis requiring steroids before stepping down to oral Pentasa. She was seen in clinic in July 2025 with symptomatic improvement on Pentasa, but CRP subsequently rose from below 40 to over 200 in the community, prompting hot clinic review.

She reports intermittent abdominal pain and episodic bloody diarrhoea, with up to 8 bowel motions per day when symptoms are active. She is not always diarrhoeal between flares. She also has worsening inflammatory joint symptoms affecting the knees, feet, ankles, hips, hands, wrists, shoulders and elbows, and reports reduced mobility. She has had night sweats, weight loss of around 5 stone over the past year, and occasional dysuria in recent weeks. There is associated fatigue and difficulty managing daily activities.

Family history is significant for IBD, with her father having had a colectomy in 2025 and a paternal uncle with Crohn's disease.

Seen in ED yesterday with generalised pain and swollen feet. Discussion with ED consultant led to discharge overnight due to hospital constraints, with planned return this morning for admission and further management.

Past Medical History:
• Ulcerative colitis - diagnosed April 2025
• Hidradenitis suppurativa
• Erythema nodosum
• IBD-associated inflammatory arthritis
• Fibromyalgia
• Iron deficiency anaemia
• Acute kidney injury stage 1

Drug History:
• Pentasa 4g PO daily
• Prednisolone 40mg PO daily, taper by 5mg weekly
• Calcium and vitamin D PO

Allergy History:
• White tape - itching

Social History:
Lives with mother, who is her carer.
Functional status significantly limited by joint pain and systemic symptoms.

On Examination:
Unwell and fatigued young woman. 
Observations: T 37.5°C, HR 113 bpm, RR 15/min, BP 121/73 mmHg, SpO2 96%.
• Abdomen: Soft, mildly tender.
• Cardiovascular: Peripheral oedema present in the feet.
• Respiratory: Nil of note.
• Other: Swollen knees and feet. Erythematous nodules on the legs.

Investigations:
• Hb 84
• WCC 13.7
• Neutrophils 11.22
• Platelets 801
• MCV 78.3
• RDW 16.3
• Creatinine 65, baseline 44
• Sodium 139
• Potassium 4.5
• Urea 2.6
• CRP 68
• Albumin 28
• Phosphate normal
• TSH normal
• LFTs: bilirubin <3, remainder unremarkable
• Chest X-ray (13/02/2025): Normal
• Pre-biologic screen (September 2025): No blood-borne viruses detected, TB Spot negative

Impression:
Acute severe ulcerative colitis with systemic involvement, including hypoalbuminaemia, inflammatory anaemia, raised CRP and stage 1 AKI.
Extraintestinal manifestations with IBD-associated arthritis, erythema nodosum and hidradenitis suppurativa.

Management Plan:
1. Admit under gastroenterology.
2. Repeat bloods to trend inflammatory markers, FBC, renal profile and albumin.
3. Repeat chest X-ray and abdominal X-ray before starting biologic therapy.
4. Start infliximab as planned once appropriate checks completed.
5. Consider azathioprine alongside biologic treatment.
6. Given active inflammation, iron infusion deferred for now; reconsider after treatment has begun and inflammation settles.
7. Discuss with senior gastroenterology team regarding need for intravenous steroids versus urgent transfer to Allerton for biologic initiation.

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Refined clerking Wed 18 March 2026 20:00

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