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So it's a clinic letter for barry jones 8 0 0 2 7 8 past medical history left robotic upper trisegmentectomy and lymph node dissection september 20 22 for lung cancer copd appendicectomy and good or hernia repair also in the past medical history admission in december 2022 with a flare up of terminal ileitis requiring operative management with a reduction in a parasecal hernia diversion of adhesions ic resection resection of meckel's diverticulum and right hemicolectomy in december 2022 most recent 3 of investigations most recent colonoscopy november 20 23 no mucosa in the: to the neo gi has multiple multiple scattered aphthous ulcers 1 flat elevated polyp in the sigmoid removed histology from the neo terminal ileum demonstrating preserved villous architecture 1 fragment demonstrating moderate active chronic inflammatory infiltrate within the lamina propria but without granulomatous dysplasia or malignancy sigmoid polyp 10 by 10 by 5 mm simple benign hyperplastic polyp how are you I'm glad to hear it well fantastic oh and tell me what stops you from living the eternal dream of happiness yeah fine are you playing the lottery okay I'm sure you would you've managed that's good I'm glad well I'll put in a good word for you and I saw you've seen us before in clinic that was a couple of years ago or spoke to us before in clinic you had some loose stools at that time and you've obviously had some operations on the bowel before I guess it'd be great to hear about what your symptoms are like at the moment yeah mhmm yep they've helped greatly fantastic fine fantastic brilliant but you didn't really understand why you're taking it no no it's difficult there's a lot of information isn't there of course I see great and it's and tell me about your stools at the moment see they're a bit firmer you said how firm is is firm yep okay fine so a little of these and and how many times a day are you going mhmm yep yep mhmm mhmm oh that's good and what what do you do for a living you said you work shifts oh really oh well what's wrong with that that's a great job isn't it very good yeah I know exactly yeah it's a tough job isn't it no oh that's good okay great fine so you work shifts you find that your bowels kind of manage around the shifts you're not having to stop the bus and go to the loo and things like that very rare yeah yeah so plan number 1 increase cholestyramine to effect number 2 blood tests including testing for fat soluble vitamins number 3 patient initiated follow-up for 12 months dear gp I had the pleasure of speaking on the telephone to mister jones today on behalf of doctor hayward in gastroenterology clinic full stop <\n\n> He was initially referred to our service following terminal ileitis and loose stools full stop his loose stools have been attributed to ibuprofen use and his terminal ileitis to this as well so his loose stools and terminal ileitis were secondary to ibuprofen full stop after a lung resection he developed an ileus and required operative management which involved an ileocecal resection and a resection of a meckel's diverticulum full stop reassuring me none of the histology from his colonoscopies nor his meckel's resections have demonstrated any evidence of inflammatory bowel disease and certainly not crohn's disease <\n\n> When he last saw doctor suarez in 2023 he started some conesevelam which he found very beneficial and has greatly improved his symptoms full stop he describes his bowels currently as a little loose still and he'll open his bowels 2 to 3 times per day mostly in the morning full stop reassuring that he doesn't have significant urgency and doesn't rush up to the toilet immediately after eating full stop he's taking the colesevelam twice a day full stop he works as a bus driver and still finds that he's able to undertake his shift the majority of the time without needing to open his bowels full stop <\n\n> We discussed today that we don't think he has inflammatory bowel disease and that his symptoms are attributed to a combination of ibuprofen use and bile acid malabsorption following his ileocecal resection full stop <\n\n> I've advised him that he can increase the dose of his colesevelam as above to improve his symptoms as long as he spaces it alongside his other medicines full stop lack of terminal ileum can result in decrease in absorption of fat soluble vitamins and so I'll send him out some blood tests including vitamin d in order to ensure that this is replete full stop <\n\n> I've not arranged to see him again in clinic but have enrolled him into patient initiated follow-up if he has any queries or concerns or his symptoms worsen despite the code of 7 I'm even more than welcome to see us in clinic again full stop yours sincerely

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Medical ST5 Miller Clerking
[Current Date] [Current Time]

Presenting Complaint:
[The reason for attendance in 1-3 words]

History of Presenting Complaint:
[Chronological narrative of current illness using short, clear sentences. Include:
- Onset, character, location, radiation, timing, exacerbating/relieving factors
- Associated symptoms
- Impact on daily activities
- Previous similar episodes
- Relevant collateral history from relatives/carers
- Any relevant background from other healthcare professionals
Do not repeat patient's name throughout. Be concise and tell a chronological story to the reader. Do not include subjective descriptions of the symptoms e.g. "severe" or use unnecessarily long words.]

Past Medical History:
[Bulleted list of significant medical conditions with relevant details:]
• [Condition with year if mentioned]
• Diabetes mellitus - latest HbA1c: [value] mmol/mol ([date])
• Asthma/COPD - latest spirometry: FEV1 [value], FVC [value] ([date])
• [Previous surgeries with dates]
• [Other significant medical history]

Drug History:
• [Drug name] [dose][units] [route] [frequency]
• [Example: Omeprazole 20mg PO OD]
• [Example: Clopidogrel 75mg PO OD]

Recently Stopped Medications: [If relevant]
• [Medication] - stopped [date/reason]

Allergy History:
[If allergies mentioned:]
• [Allergen] - [Reaction type] ([severity if mentioned])
• NKDA [if no known drug allergies stated]

Social History:
[Living situation. Who they live with, housing type, if mentioned]
[Mobility. Walking aids, stairs, transfers, if mentioned]
[Carers. Formal/informal care arrangements, if mentioned]
[Occupation. Current/previous if relevant, if mentioned]
[Smoking. Never/Ex-smoker/Current - pack years if mentioned]
[Alcohol. Units per week/Never/Ex-drinker - if mentioned]
[Functional Status: Impact on activities of daily living, if mentioned]

On Examination:
[General Appearance. Alert, well/unwell, distressed, if mentioned]
Observations:: [If mentioned - HR, BP, Temp, RR, O2 sats (do not use subscripts)]
• Abdomen: [Inspection, palpation, percussion, auscultation findings. If not commented upon, document as normal]
• Cardiovascular: [Heart sounds, murmurs, peripheral pulses, oedema. If not commented upon, document as normal]
• Respiratory: [Chest expansion, percussion, auscultation. If not commented upon, document as normal]
• Neurological: [If examined.]
• Other: [Any other relevant examination findings, if mentioned]

Investigations:
• [Test name] ([date, if mentioned, do not include include today's date on results, list without a date]): [Result without units]
• [Example: Hb 85]
• [Imaging type] ([date, if mentioned]): [Key findings]
• [Example: CT Abdomen/Pelvis (15/03/24): Sigmoid diverticulosis, no perforation]

Impression:
[Main diagnosis]
Differential Diagnoses: [Only if multiple possibilities discussed]
[Secondary issues. Relevant comorbidities affecting management. If mentioned]

Management Plan:
1. [A numbered list documenting the management plan to be undertaken, if mentioned, include:
- Immediate management/monitoring,
- Investigation requests,
- Treatment interventions - medications, procedures,
- Discharge planning/follow-up arrangements,
- Patient education/lifestyle advice,
- Referrals to other specialties if needed,
- Which ward or specialty the patient would be best admitted to e.g. "Respiratory Bed",
- Escalation plan that was discussed - whether the patient is suitable for CPR, ITU and/or NIV.]

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Patient Name MRN

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