Physician's Assistant

Patient Details

Refined clinic letter (272 days ago 11:34)

Refined clinic letter Tue 08 July 2025 11:34

Last Modified: 272 days ago

MRN:

Content:

Diagnosis:
Functional dyspepsia with early satiety and weight loss
IBS with predominant constipation
Gastro-oesophageal reflux disease

Other Medical Diagnoses:
• Fibromyalgia
• Hysterectomy and bilateral salpingo-oophorectomy
• Cholecystectomy
• Soft tissue abnormality on MRI leg - awaiting repeat MRI as discussed in sarcoma MDT

Current Medications:
• Laxido - patient discontinued due to tolerability issues
• Senna 15mg PO nocte - STARTED TODAY

Investigations:
• OGD (January 2025): Normal mucosal appearances, no histology required
• Thoracic CT (2025): Normal
• Coeliac screen: Normal
• H. pylori: Normal
• qFIT: Normal
• Faecal calprotectin (March 2025): 116 μg/g
• Faecal calprotectin (February 2025): 163 μg/g
• Colonoscopy (May 2025): 2 subpedunculated polyps <5mm in sigmoid colon excised, 1 subpedunculated polyp <5mm in rectum excised. Endoscopic findings: mild erythema from splenic flexure to rectum, no loss of vascular pattern. Histology: sigmoid polyps - sessile serrated lesion without dysplasia, rectal polyp - benign hyperplastic polyp, terminal ileal biopsies - normal, colonic biopsies - preserved crypt architecture, no increase in intraepithelial lymphocytes, normal cellular lamina propria, no dysplasia or malignancy, no infective organisms, no significant pathological abnormality

Management Plan:
1. Trial of Senna 15mg nocte for constipation management
2. Patient initiated follow-up available over next 12 months if Senna ineffective
3. Consider linaclotide if Senna proves inadequate for IBS-C symptoms
4. Continue dietary modifications as tolerated
5. Monitor reflux symptoms - likely secondary to constipation

I had the pleasure of speaking on the phone to Mrs Ugaldi in gastroenterology clinic.

Mrs Ugaldi continues to experience abdominal pain mainly around defecation, uncontrolled heartburn and early satiety with associated weight loss. She has been experiencing productive cough with yellow sputum since November. Her reflux symptoms include heartburn with burning retrosternal pain and acid regurgitation. She reports intermittent constipation without clear dietary triggers, followed by periods of loose stools. She had been taking Laxido but discontinued this due to tolerability issues. She has tried dietary modifications including flaxseed and chia seeds but these caused significant pain, likely due to the high fibre content causing gut sensitivity.

Her recent investigations have been reassuring with normal OGD in January 2025, normal coeliac screen, H. pylori and qFIT. Faecal calprotectin levels have been mildly elevated at 116-163 μg/g. Recent colonoscopy in May 2025 showed benign polyps which were removed with reassuring histology showing no dysplasia or malignancy.

I have started her on Senna 15mg nocte which should help with her constipation. I suspect her reflux symptoms are secondary to the constipation causing delayed gastric emptying. I have arranged patient-initiated follow-up over the next 12 months should the Senna prove ineffective, at which point we can consider linaclotide for IBS with predominant constipation. I will write to her GP to add Senna to her repeat prescriptions.

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Patient Details

Refined clinic letter Tue 08 July 2025 11:34

Field Clipboard (for EPR paste)

Tasks

Feedback