Transcription - 20250530T 11-58.mp3

Next patient thomas o'keefe alpha 4 1 6 5 1 5 investigations most recent colonoscopy november 20 12 mild mucosal inflammation noted the rectum with erythema rest of the: appeared normal serial biopsies taken diagnosis ulcerative colitis diagnosed managed with pentase tablets the subsequent gentase suppositories plan number 1 routine colonoscopy for ibd surveillance number 2 signposting to ibd nurses number 3 blood tests in light 5 asa use number 4 follow-up in 12 months whoever can contact the ibd nurses if wishes to be seen sooner full stop I had the pleasure of speaking on the telephone to mister o'keefe on behalf of doctor hayward in gastroenterology clinic today full stop <\n\n> He is referred back to us by his gp after he fell off our follow-up list full stop he was last seen in '14 and has a diagnosis of ulcerative propeptitis which was diagnosed in 2012 full stop he describes that he has good regular bowel habits however will experience a flare up 1 or 2 times per year which are often stress related full stop when he experiences these flares he'll have some tummy pain particularly in the left cardiac fossa and have fresh red pr bleeding with urgency in mucus with stools full stop stools will be watery full stop reassuringly, he doesn't feel systemically unwell during these episodes and they last only a couple of days full stop they responded very well to using pentasa suppositories which he'll use for 1 week around the of a flare full stop <\n\n> He's never needed any other treatment for his ulcerative proctitis full stop <\n\n> The terms of his life more generally, he has a wife and 2 children he's a nonsmoker but does drink alcohol in moderation he's a butcher in a family business full stop <\n\n> We discussed today that it sounds as though he's keeping his disease under control with suppositories however if he starts to flare more than 2 times per year or is developing a flare that has not responded to his suppositories then we'd like to know about it because there's further options for treatment that we can offer including oral treatments and you can get in contact with myself either the secretaries or the ibd nurses full stop <\n\n> He's due some colouroscopic surveillance given his diagnosis in 2012 and I'll request this for him to keep an eye on his ulcerative proctitis full stop he should also have some blood tests in like his 5 asa use and I'll request these for him he can have these taken at windsor house between 8 and 5 or 8 and 04:30 monday to friday full stop <\n\n> I look forward to seeing him back in clinic in a year's time however he's more than welcome to get back in contact with us sooner if things change or he has questions stop your soliciting

Diagnosis:
Ulcerative proctitis diagnosed 2012

Other Medical Diagnoses
- Asthma
- Guttate psoriasis
- Blepharitis
- Allergic rhinitis
- Recurrent erosion of cornea

Medications:
- Mesalazine 1g suppositories - to be used as directed
- Salamol 100micrograms/dose inhaler - two puffs four times a day
- Clenil Modulite 100micrograms/dose inhaler - two puffs twice daily

Investigations:
- Colonoscopy November 2012: Mild mucosal inflammation noted in the rectum with erythema, rest of the colon appeared normal. Serial biopsies taken.

Plan:
1. Routine colonoscopy for IBD surveillance
2. Signposting to IBD nurses
3. Blood tests in light of 5-ASA use
4. Follow-up in 12 months - however can contact the IBD nurses if wishes to be seen sooner

I had the pleasure of speaking on the telephone to Mr O'Keefe on behalf of Dr Hayward in gastroenterology clinic today.

He is referred back to us by his GP after he fell off our follow-up list. He was last seen in 2014 and has a diagnosis of ulcerative proctitis which was diagnosed in 2012. He describes that he has good regular bowel habits, however will experience a flare up 1 or 2 times per year which are often stress related. When he experiences these flares he'll have some tummy pain particularly in the left iliac fossa and have fresh red PR bleeding with urgency and mucus with stools. Stools will be watery. Reassuringly, he doesn't feel systemically unwell during these episodes and they last only a couple of days. They respond very well to using Pentasa suppositories which he'll use for 1 week around the time of a flare.

He's never needed any other treatment for his ulcerative proctitis.

In terms of his life more generally, he has a wife and 2 children, he's a non-smoker but does drink alcohol in moderation, he's a butcher in a family business.

We discussed today that it sounds as though he's keeping his disease under control with suppositories, however if he starts to flare more than 2 times per year or is developing a flare that has not responded to his suppositories then we'd like to know about it because there's further options for treatment that we can offer including oral treatments, and he can get in contact with myself either via the secretaries or the IBD nurses.

He's due some colonoscopic surveillance given his diagnosis in 2012 and I'll request this for him to keep an eye on his ulcerative proctitis. He should also have some blood tests in light of his 5-ASA use and I'll request these for him. He can have these taken at Windsor House between 8 and 5 or 8 and 4:30 Monday to Friday.

I look forward to seeing him back in clinic in a year's time, however he's more than welcome to get back in contact with us sooner if things change or he has questions.

Summary

Investigations

Plans