Physician's Assistant

Refined clerking (19 days ago 19:54)

Refined clerking Wed 18 March 2026 19:54

Last Modified: 19 days ago

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Presenting Complaint:
Acute severe ulcerative colitis flare

History of Presenting Complaint:
21-year-old lady with a background of ulcerative colitis diagnosed in April 2025. She was admitted in June 2025 with a flare of erythema nodosum on a background of hidradenitis suppurativa, and a further admission with a UC flare treated initially with steroids before switching to oral Pentasa. She was seen in clinic in July 2025 with symptomatic improvement on Pentasa, with referrals made to Rheumatology and Dermatology. Since then, her CRP has risen from below 40 to around 200 in the community, and she has required two short courses of steroids.

She presented to the Emergency Department yesterday with generalised abdominal pain and swollen feet. Blood tests showed significant inflammation, anaemia, thrombocytosis and a mild AKI. She was discussed with the ED consultant and discharged overnight due to hospital constraints, with review arranged in AMU today.

She reports intermittent abdominal pain, usually worse in the mornings and related to food. When symptomatic, she opens her bowels up to 8 times a day, with blood in some motions and on the toilet paper. She also has intermittent diarrhoea and episodes of vomiting. She describes urgency and occasional dysuria over the past few weeks. She has had night sweats, worsening joint pains and swelling affecting the knees, feet, ankles, hips, hands, wrists, shoulders and elbows. She has lost around 5 stone over the past year. Her mother reports marked functional decline and difficulty with mobility.

There is a family history of IBD, including her father who underwent colectomy in 2025 and a paternal uncle with Crohn’s disease. She is currently taking Pentasa and has also been on prednisolone 40mg daily, tapering by 5mg weekly, as well as calcium and vitamin D. The plan had been to start infliximab and azathioprine, pending pre-biologic assessment and chest radiography.

Past Medical History:
• Ulcerative colitis, diagnosed April 2025
• Hidradenitis suppurativa
• Erythema nodosum
• IBD-related arthritis
• Fibromyalgia
• Iron deficiency anaemia
• Previous admissions in June 2025 for UC flare and erythema nodosum
• Family history of IBD

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

Allergy History:
• White tape - itching

Social History:
Lives with family and her mother provides support/care. Significant impact on mobility and daily function due to inflammatory symptoms, pain and fatigue.

On Examination:
Appeared unwell.  
Observations: T 37.5°C, HR 113 bpm, RR 15/min, BP 121/73 mmHg, SpO2 96%
• Abdomen: Soft, mildly distended and tender. No peritonism described.
• Cardiovascular: Peripheral swelling noted in the feet. Tachycardic. No murmur described.
• Respiratory: Chest clear on examination.
• Other: Puffy, swollen feet. Arthralgia with widespread joint pain. Erythematous lumps on the legs consistent with erythema nodosum.

Investigations:
• Hb 84
• MCV 78.3
• RDW 16.3
• WCC 13.7
• Neutrophils 11.22
• Platelets 801
• Creatinine 65 (baseline 44)
• Sodium 139
• Potassium 4.5
• Urea 2.6
• Albumin 28
• CRP 68
• TSH normal
• Bone profile normal
• LFTs: bilirubin <3, remainder normal
• Phosphate normal
• Chest X-ray (13/02/25): Normal
• Pre-biologic screen (09/2025): No blood-borne viruses detected; TB spot negative

Impression:
Acute severe ulcerative colitis flare with systemic involvement.  
Iron deficiency/microcytic anaemia, thrombocytosis, hypoalbuminaemia and raised CRP.  
AKI stage 1.  
IBD-related arthritis with extraintestinal manifestations including erythema nodosum and hidradenitis suppurativa.

Management Plan:
1. Discuss with senior gastroenterology team and arrange transfer to Allerton for biologic initiation.
2. Commence infliximab once appropriate, with azathioprine planned as part of biologic strategy.
3. Consider a short course of steroids to bridge symptoms while awaiting biologic treatment, depending on senior review.
4. Repeat blood tests to monitor inflammatory markers, renal function, FBC and trends.
5. Arrange repeat chest X-ray and abdominal X-ray prior to biologic treatment to exclude complications.
6. Defer iron infusion for now due to active inflammation; reconsider after first infliximab dose and improvement in inflammatory burden.
7. Ongoing Rheumatology input for IBD-related arthritis and extraintestinal manifestations.
8. Continue current supportive treatment including calcium and vitamin D as prescribed.

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Refined clerking (19 days ago 19:55)

Refined clerking Wed 18 March 2026 19:55

Last Modified: 19 days ago

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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.

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Refined clerking (19 days ago 20:00)

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 (20 days ago 14:45)

Refined clerking Tue 17 March 2026 14:45

Last Modified: 20 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Acute severe UC flare

History of Presenting Complaint:
Bethany is a 21-year-old lady with a known diagnosis of ulcerative colitis (UC) since April 2025, presenting with an acute flare. She initially attended the Emergency Department yesterday with generalised abdominal pain and swollen feet and was discussed with the ED consultant. Due to hospital capacity constraints, she was discharged overnight and asked to return to AMU this morning.

She describes a relapsing-remitting course since her diagnosis. When symptomatic, she is opening her bowels up to 8 times per day, with blood present on some occasions, noted on the paper and in the toilet. Outside of flares, bowel frequency is normal. She also experiences intermittent nausea with occasional vomiting and diarrhoea. She has been modifying her diet, including reducing portion sizes, with some improvement.

She reports significant joint pain affecting the knees, feet, ankles, hips, hands, wrists, shoulders, and elbows, with associated swelling of the knees and feet noted. This is in the context of known fibromyalgia and IBD-related arthritis. She also reports erythema nodosum on her legs, ongoing issues with hidradenitis suppurativa, and generalised fatigue. She notes that physical exertion requires considerable effort. She has experienced night sweats. She has also intermittently noted dysuria over the past few weeks.

She has lost approximately 5 stone over the past year. She has had multiple short courses of steroids since July 2025 in the community due to rising CRP. Her CRP has been chronically elevated since April 2025, reaching a peak of 227 in September 2025.

A plan to commence infliximab and azathioprine was established at a previous clinic appointment pending a pre-biologic screen and chest X-ray. The chest X-ray performed on 13/02/2026 was reported as normal, fulfilling the requirement for biologic initiation.

Collateral history provided by her mother, who acts as her informal carer.

Past Medical History:
• Ulcerative colitis - diagnosed April 2025
• 2 inpatient admissions June 2025: (1) erythema nodosum flare; (2) UC flare treated with steroids then transitioned to oral Pentasa
• Hidradenitis suppurativa - multiple courses of antibiotics
• Erythema nodosum
• IBD-related arthritis - under Dr Winfield, Rheumatology
• Fibromyalgia - under Dr Winfield, Rheumatology
• Iron deficiency anaemia
• Family history: Father with colectomy; paternal uncle with Crohn's disease

Drug History:
• Pentasa 4g PO OD (granules)
• Prednisolone 40mg PO OD for 1 week, then reducing by 5mg weekly until nil
• Calcium and Vitamin D supplementation (dose not specified)

Allergy History:
• White surgical tape - contact irritation/pruritus

Social History:
Lives with mother, who provides informal care. Significant functional limitation due to joint pain and fatigue affecting mobility and activities of daily living.

On Examination:
General Appearance: Unwell-appearing young lady, visibly fatigued.
Observations: HR 113, BP 121/73, Temp 37.5°C, RR 15, O2 sats 96%
• Abdomen: Mild discomfort on palpation. Pitting oedema of the lower limbs noted bilaterally, consistent with hypoalbuminaemia.
• Cardiovascular: Heart sounds present. Bilateral lower limb oedema noted.
• Respiratory: Chest clear on auscultation.
• Other: Erythema nodosum lesions noted on the legs. Swelling of knees and feet. Skin generally pruritic.

Investigations:
• Hb: 84 (previously 123)
• Platelets: 801
• Neutrophils: 11.22
• WCC: 13.7
• MCV: 78.3
• RDW: 16.3
• Creatinine: 65 (baseline 44)
• Sodium: 139
• Potassium: 4.5
• Urea: 2.6
• CRP: 68 (chronically raised since April 2025; peak 227 in September 2025)
• Albumin: 28
• Bilirubin: <3
• Remainder of LFTs: Normal
• Bone profile: Normal
• Phosphate: Normal
• TSH: Normal
• Pre-biologic screen (September 2025): No blood-borne viruses detected; TB-SPOT negative
• Chest X-ray (13/02/2026): Normal

Impression:
Acute severe ulcerative colitis with evidence of systemic involvement:
• Hypoalbuminaemia
• Microcytic anaemia secondary to inflammation and iron deficiency
• AKI stage 1
• Raised CRP
• Flare of IBD-related arthritis
• Extraintestinal manifestations: erythema nodosum and hidradenitis suppurativa

Management Plan:
1. Urgent transfer to Allerton Ward for initiation of infliximab; pre-biologic screening and chest X-ray requirements have been fulfilled.
2. Repeat chest X-ray and abdominal X-ray prior to commencing biologic therapy to exclude complications.
3. Repeat bloods to trend inflammatory markers and renal function.
4. Commence a short course of prednisolone as a bridge to infliximab to provide symptomatic relief in the interim; dose to be confirmed following discussion with senior colleague.
5. Azathioprine to be commenced alongside infliximab as per prior plan.
6. Iron infusion to be deferred until after the first dose of infliximab and once inflammation has been adequately controlled, given current infection risk in the context of active inflammation.
7. ECG requested given sinus tachycardia on admission.
8. Discussion with consultant regarding the above plan prior to transfer.
9. Consider blood transfusion given Hb of 84, in context of symptomatic anaemia - to be reviewed following consultant discussion.
10. Dermatology and rheumatology follow-up already in place; ensure ongoing input from both teams is maintained.

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Refined clerking Wed 18 March 2026 19:54

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Refined clerking Wed 18 March 2026 19:55

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Refined clerking Wed 18 March 2026 20:00

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Refined clerking Tue 17 March 2026 14:45

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