37 y/o M, history of ulcerative colitis for 5

years, complaining of increasing bowel

frequency and loose stool.

- Left sided disease

- On oral and enema 5-ASA and steroid enema
- Good compliance
- Had acneiform rash once and muscle aches before, not actively
- About 7-8 times a day in the past month, a/w bloody and
mucoid stool and lower abdominal cramps
- Fecal urgency +ve but no tenesmus
- Mild anaemic symptoms
- Loss of 3kg in a month, mildly loss of appetite, no subjective
feeling of fever
- No oral and peri-anal disease
- no joint pain, no visual problem, no spinal stiffness
- Brother has Crohn disease diagnosed at 30 y/o
- Negative TOCC
- Good past health
- Not taking other drugs
- No smoking and drinking
- Live with family
- Lawyer

→disease extent: pan colitis, left side, right side →monitor symptoms: BO __ times/day,
bleeding →measure body weight every visit

→drug side effects

o sulfasalazine: N&V

o azathioprine: leucopenia
o biologics: TB, hepatitis B flare, infection

o steroid: Cushing’s
→disease activity
o acute phase reactants: ESR, CRP

o long term activity: anemia, albumin

DDx:
- Disease flare up (clarify treatment issue, consider step-up)
- Infective: bacillary dysentery (salmonella, shigella), Amebic colitis, CMV colitis, C. diff
- Drug: antibiotics associated diarrhea, laxatives
- Malignancy: UC increases the risk of CRC

Hx:
- Stool frequency and consistency
- Abdominal pain/cramps
- Urgency
- Tenesmus
- Any blood and mucus in stool (clarify details? Colour, character, amount etc)
- fever, weight loss, anorexia, anaemia
- any oral and peri-anal involvement
- extra-intestinal manifestations (eyes, skin, MSK, HB, urinary tract)
- Disease control:
o On what drugs for UC
o Compliance
o S/E
- PMH and DHx:
o Any recent infectious GE
o HIV, TB, Hep B
o Co-morbidities
o Any drug use, esp. Antibiotics and laxative
o Any abdominal surgeries such as appendectomy
- FHx and SHx:
o FHx of IBD, CRC
o Smoking, drinking
o TOCC, food history
o Occupation, ADL
o social status

P/E:
- vital signs:
o pulse, BP, temperature
- hydration status:
o mucous membrane
o skin turgor
o JVP
o Capillary refill
- Nutritional status:
o Cachexia
 o Temporal wasting
o Reduced tricep fold thickness
- Abdomen:
o Finger clubbing
o Jaundice
o Surgical scars
o Abdominal distension
o Abdominal tenderness, peritonism
o Detect masses
o Bowel sounds
o Don’t forget oral and anal examination
- Extra-intestinal:
o fundoscopy, visual acuity
o Spinal/joint swelling, tenderness, ROM, posture
o Any skin lesion/ulcer

Ix:
- Bloods:
o CBC
o CRP, ESR
o Clotting
o LRFT, electrolyte, CaPO4, Mg
o Iron profile, B12/folate
o 25-OH vitamin D3
o ASCA, pANCA
o HBV serology
o CMV serology
o IGFR
- Stool:
o Microscopy
o Culture
o Viral studies
o EIA for toxins
o Calprotectin
- Imaging:
o AXR
o CXR
o Barium enema
o CT +/- MRI abdomen and pelvis
o CT enteroclysis
- Colonscopy
o evaluate disease extent and mucosa appearance macroscopically
o obtain histology microscopically
o survey for CRC

Mx:
- read SONIA, cannot type this part in time