So it's clinic letter for natalie thomas alpha221855 41 year old lady it's a new patient investigations ogd february 2025 but dysphasia normal mucosal appearances of the esophagus 4 cm hiatus hernia clotest negative histology from the esophagus no pathological abnormality other medical problems lichen planus dysmenorrhea anxiety low b 12 20 16 benign joint hypermobility 02/2009 medication list stexorol d 3 1000 units per day evorel 50 patches 1 twice per week progesterone 100 microgram sorry 100 mg 2 tablets 2 hours before bedtime for 14 days of the month mounjaro kwikpen private prescription allergies ferrous fumarate mefenamic acid codeine phosphate gabapentin amitriptyline I refer from the gp I appreciate if you could see this lady who has a recurrent history of bowel problems in terms of diarrhea and mucus oral ulceration for many years associated with low iron vitamin d levels and borderline low b 12 she's not underweight and has been managing her diet with the help of dietitian friends she has a positive capotectin of a 152 so check the investigations lecal calprotectin may 2025 a 152 vitamin d january 2025 15 1 5 ferritin may 2025 24 without anemia anti intrinsic phantom antibodies negative may 2025 anti ttg negative march 2025 she says that when she was 19 she was diagnosed with crohn's by doctor dalton and truro and retracted a couple of years later she's not been on any active treatment referred to gastroenterology in 2019 but I have no records of her ever being seen chronic low iron level generally unwell appreciate she could be sent allergic to the past medical history ibs mixed anxiety and depression drug overdoses fibromyalgia chronic fatigue benign joint hypermobility depression gestational diabetes iron deficiency anemia hi is that natalie thomas hi my name is doctor rob miller I'm 1 of the gastroenterology registrar hi have I caught you at a reasonable time oh fine good how are you really fine mhmm okay mhmm yeah okay mhmm okay okay okay mhmm okay okay yeah yeah slightly high mhmm yeah yeah mhmm alright what happens okay I'm sorry yeah yeah well of course so since since christmas time is when you first noticed it all sort of get worse but obviously you've been having these symptoms since you were yeah I I'm not into that kind of thing so yeah yeah yeah funny funny okay so so taking me back to when so you're having recurrent episodes of tummy pain when you were a teenager mhmm mhmm okay with with lustool fine okay you admit it mhmm yeah and did he give you any did you have any treatment for crohn's disease what did you take you took steroids prednisolone that's okay k yeah I understand I'm sorry mhmm mhmm okay is it 1 knee more than the other or both knees both knees mhmm tell me about your spine where where whereabouts on your back is it painful right in your buttocks okay mhmm and then you said the fingers your hand the joints in your hands are painful no okay and has that all been has that been for years or is that in the last 6 months or okay yeah right yeah it doesn't yeah I well you have you have some notes but I don't have any record of you having yeah any sort of diagnosis of that from us for so obviously you know we're still on bits of paper so but but yeah yes you've got a busy life have you got a family and things like that yeah yeah but I've got kids that I need to crack on yeah I understand tell tell me about your family do you you have kids mhmm good yeah your brother's got crohn's has any of your parents got crohn's okay yeah definitely not as bad as doctors but pretty bad okay so she's got diverticulosis fine and what do you do for him what do you do for a living are you of course I completely understand yeah fine so so you've had symptoms for many years that previous diagnosis of crohn's disease but never put on anything long term for the crohn's disease often we'll find that it takes time to get to see the diagnosis of crohn's and the interpretation of results is very grey you know what some people think is indicative of an inflammatory bowel disease like crohn's disease for other people may not think so rinking did you ever have a colonoscopy no you did fine steroids alright I'm sorry yeah fine yeah completely yeah but we yeah but we can we can still work with with you know we I can try and get those results from from that private hospital but I worry that I might not be able to get them but I can do my best to try and get the secretaries to to pull so your symptoms are predominantly fatigue big painful joints low back pain and then what about your bowels okay mhmm mhmm what happens when you have a fire bump okay okay yeah do you reduce the amount you eat because you don't wanna get the symptoms yeah fine yep I understand and then in terms of your bowels you said you you get loose stools with fiber but the rest of the time what are your pus like never get constipation mhmm yep mhmm like as in it'll get be painful and then get better yeah and then in do you have loose stools all the time not all the time so you'll a lot of you'll more often be loose than firmed or is that unfair to say yeah fine okay mhmm okay yeah fine and how many times a day will you go when it's urgent and loose mhmm okay yeah so it'll be first thing in the morning for example you go 5 times and then the rest of the day you'll be okay okay so it can happen during the middle of the day fine and then how and then will you experience that for a week or will you experience that just for the day and then the next day you'll go back to normal mhmm okay so greater than a week yeah fine okay fair enough and any blood or mucus okay yeah fine and do is it painful when you pass stool it is sore is it painful around your bum I mean it is yeah but from wiping a lot it can be very sore mhmm yep endometriosis or okay oh adenomycosis yeah fine yeah yeah and you're having quite heavy periods then were you yeah and what are your periods like at the moment are they particularly heavy don't have any fine you take that progesterone pill don't you I'm with you oh really fine so you had all of your endometrium ablated fine I'll have a look at the letters fine thank you and then in terms of the other medicines that you're on I see there's a prescription for mounjaro when did you start taking that okay yeah fine mhmm did you notice an effect on your weight at all or was that why you were doing it or okay yeah and how much do you weigh at the moment if you have you checked recent I think we all say that yes yeah very healthy mhmm okay okay mhmm alright and how tall are you if don't mind me asking 5 to 6 great fine and have you noticed any unintentional weight loss said your weight's quite variable but overall you haven't noticed a gradual downward trend good yeah fine fair enough I think so thank you for telling me all of that I mean it certainly sounds like you have significant symptoms you can see changes on your blood test in keeping with potential malabsorption and we've got this red stool test for inflammation all of those things make me think we should have a closer look at this I think the best way to do that would be another colonoscopy probably to look into your small bowel yeah sorry I think you've got multiple reasons to need that there's the potential for inflammatory bowel disease which we should investigate we should investigate someone who has fresh red rectal bleeding because there's always a colic or something sinister close to the back passage that we should look at so I think both of those things would be sensible reasons to have a colonoscopy and I can book that for you urgently in terms of potential for small bowel disease with the pain you're getting things like that the colonoscopy will be able to look into the very last part of the small bowel but it won't be able to get further up and we know that crohn's disease can affect any part of the bowel so I suggest an mri scan of your small bowel if that's okay so those 2 things together should give us a really close look at your large bowel and your small bowel we can of course when do you start in september yeah fine think you should get the colonoscopy before then the mri scan like I say book it urgently they usually do them quite quickly but I can't promise it'll be done before we've got 2 months so I think it should be done we aim for 6 weeks for these things it should be done but the I mean the colonoscopy is obviously burdensome to have the prep and things like that but the mri scan you don't need to be prepped for or anything like that so really prep is a shorter fast and then combined with that I mean without the strong laxatives to wash everything through they'll still be solid stool and so we won't be able to see very much and then it kind of you undergo the procedure but without any benefit from it we do have new preps which we are using at the moment which lots of patients say is much better than previous preps so this plendview that we're using citrifle exactly can be really serious whereas this blendview it may not taste so nice but people say that it's a bit better in terms of the effect it has on them than the citrifle so I hope should be more tolerable have you had yeah sorry it's not very nice but it it's the only way to really get a feeling for what's going on in terms of recent blood tests you had some back in may they checked your they checked your celiac screen which is negative they looked at whether you had intrinsic factor antibodies for pernicious anemia which you don't have but and they checked your ferritin again which was still low then despite they replaced your b 12 in the past I can see and they replaced your vitamin d which had brought it up slightly they didn't check your kidney function and we should check your kidney function before you have the prep the last kidney function we have is back in january so I'll put some blood tests on the system for you if that's alright and you can come get them done sorry again yeah windsor house now is the flow to me for the so I'll put them in the system now you can come get them done from now onwards and then I'll request the colonoscopy as well once I've got the results of those and then we and the mri scan will take it from there is that alright any questions or anything I've forgotten or anything like that good yeah it's good to stick to expectations yeah yeah well as I say I will try and get them from from sort of the royal cornwall if they're there or if they're which hospital did he say it was that again the duchy yeah fine I'll try and see if I can get them to be sent across to me but it can sometimes be difficult but I will try alright exactly I'll write to you as the results come back and then depending what the results show I'll book you a clinic appointment chat to us again with the results I'll probably book you a safety clinic appointment for 3 months time to and then at that. We'll have everything but I hope to be in contact sooner with the results in the plan is that okay not always at all it was nice to meet you and maybe we'll see for the a and e sometime yeah it really is a maze yeah much nicer yeah I don't envy you I'm like you know any old time alright nice nice talk to you bye bye so in the clinic letter I had the pleasure of speaking to miss thomas in gastroenterology clinic today on behalf of professor lewis full stop the consultation was conducted over the telephone full stop I'm sorry to hear about the symptoms she's been experiencing for nearly as long as she can remember full stop she says that from age 8 she would have to be taken out of school with recurrent episodes of abdominal pain associated with diarrhea full stop at some time during her childhood she was hospitalized with these symptoms full stop at age 19 she saw doctor dalton as a private patient and was diagnosed with crohn's disease and started on prednisolone full stop she wasn't started on anything long term for her crohn's disease full stop she underwent a colonoscopy at this time but unfortunately I don't have any of these clinical results or letters full stop in terms of her symptoms at the moment, she says that things have been particularly severe over the last 6 months where she's been feeling fatigued and under the weather full stop she'll experience joint pain with her bilateral knees being painful and occasionally swollen as well as her lower back but not her buttocks full stop she also experiences pain and swelling in the joints of her hands full stop she'll notice that these symptoms are worse when her bowels are worse and quote flaring quote full stop she says that her bow <\n\n> She says that her bowels have always been an issue full stop she finds that eating any fiber will cause her to have diarrhea and abdominal pain and she finds that she restricts her diet to foods which she'll be able to tolerate full stop she's tried a fodmap diet and this has had no effect full stop her bowels are usually loose type 6 to 7 on the sorry 5 to 6 on the bristol stool chart and she can go up to 5 times a day or over 5 times a day for over a week when her bowels are worse full stop she's also had several episodes of passing mucus and several episodes of bright red blood associated with pain in her back passage full stop <\n\n> It tells her family history, her brother has crohn's disease but there's no other family history of inflammatory bowel disease full stop it tells her life more generally, she has 2 children aged 13 she has a supportive partner and works as an occupational therapist she's soon due to start in a and e full stop <\n\n> Reviewing her medicines I know she's was prescribed mounjaro but she only took this for 8 weeks, doesn't associate this temporally with any of her symptoms and has subsequently stopped this full stop <\n\n> I explained that we have her symptoms which sound like they've been long standing and significant with loose stools and pain we have evidence of malabsorption on her blood tests with low vitamin b 12 low vitamin d and low ferritin in the recent past and we have her raised fecal caprotectin at 152 all of these. Towards the potential for an inflammatory bowel disease however we should do some more tests to investigate this full stop I've explained that a colonoscopy with terminal ileal intubation and biopsies from the terminal ileum as well as the remainder of the: would be sensible as well as an mri scan of her small bowel in order to investigate the potential for small bowel crohn's disease full stop <\n\n> She needs some blood tests prior to her colonoscopy to check her kidney function and I've requested these for her on our online requesting system full stop <\n\n> I'll book her an appointment in 3 months' time to discuss the results however I hope to be in contact sooner as the results come through to me full stop again at the top of the letter we have anthropometry weight 18 stone height 5 foot 6 pounds open brackets patient reported close brackets and then in the plan number 1 blood tests including kidney function number 2 mri small bowel number 3 colonoscopy with terminal ileal intubation, terminal ileal biopsies and colonic biopsies booked as 2 week wait due to symptoms of rectal bleeding number 4 clinic follow-up in 3 months number 5 right with results thank you