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Patient Details

Refined clinic letter (290 days ago 10:17)

Refined clinic letter Fri 20 June 2025 10:17

Last Modified: 290 days ago

MRN:

Content:

Diagnosis:
6 months of loose stool, abdominal pain and weight loss - investigating for Crohn's Disease

Other Medical Diagnoses:
• No significant past medical history

Current Medications:
• None

Investigations:
• Stool Culture (May 2025): Negative for Campylobacter, Salmonella, Shiga toxin, Shigella, Cryptosporidium and Giardia
• Faecal Calprotectin (May 2025): 261 mcg/g (elevated)
• Blood tests (May 2025): CRP 55 mg/L (elevated), Neutrophilia 9.6, WCC 14.1, Monocytosis 1.14, Eosinophilia 0.81, Platelets 478
• Coeliac serology (May 2025): Negative

Anthropometry and Observations (from GP record): BMI 18, blood pressure 125/75, pulse 59

Management Plan:
1. MRI Small Bowel - urgent
2. Colonoscopy with ileocolonic biopsies and terminal ileal intubation - urgent
3. Blood tests including pre-immunosuppression screening at Windsor House
4. Follow-up appointment with results in 6-8 weeks

I had the pleasure of speaking on the telephone to Mr Elliott in gastroenterology clinic today on behalf of Dr Klimova.

Many thanks for referring him to us. I was sorry to hear about the symptoms he's been experiencing for the last 6 months with loose stools, passing type 5-6 stools without blood 3-4 times during the day and up to 5-6 times at night. Associated with this he's had systemic symptoms of fatigue and weight loss of over 1.5 stone over the last 6 months. He doesn't describe any eye or skin symptoms but does experience lower back pain which tends to peak when he has abdominal pain.

In terms of abdominal pain, he experiences colicky lower abdominal pain which will last 4-5 minutes before resolving.  If he passes stool this will ease the pain.

In terms of his life more generally, he lives with wife and child who are well.  He works in office work for a security company and does not smoke.  He has no family history of inflammatory bowel disease.  He has recent travel history where he went to Tenerife for a week but this does not temporally correlate with his symptoms.

We discussed that his investigations demonstrate raised inflammation in terms of blood tests and stool tests and investigating these with colonoscopy and an MRI scan of the small bowel would be sensible.  It would be prudent to get some blood tests to exclude other causes of diarrhoea as well as a pre immunologic screen and I have requested these on our electronic requesting system in order that he can have them performed at Windsor house.

We briefly discussed the potential diagnosis of inflammatory bowel disease and the treatments which can be offered.

We look forward to seeing him back in clinic in 6-8 weeks' time with the results of these investigations to discuss further.

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Refined clinic letter Fri 20 June 2025 10:17

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