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You are the FY1 on the gastroenterology ward. Dom Peridone is a 26-year-old man attending for an outpatient appointment as he is living with a long-term condition. He attends appointments every six months.

His medications include azathioprine.

Please take a history from Dom, and perform a relevant examination, ensuring to explore the impact that his condition has on his life, and his concerns about the future.

You are Dom Peridone, a 26-year-old young man who was diagnosed with Crohn’s disease six years ago at the age of 20. You are here today for an outpatient appointment; you attend these every six months. You are currently a PHD student, reading Psychology, and are in your final year of your PHD.

HPC: You were diagnosed with Crohn’s disease when you were in your second year of university. You experienced about two months of bloody diarrhoea that became more and more frequent, and lost about a stone and a half in weight. You also got really painful ulcers in your mouth. This was quite embarrassing for you as a university student and it took you a little while to present. In fact, you didn’t go and see anybody about it until a particularly bad week when you experienced horrific abdominal pains, and very frequent bloody diarrhoea- up to 8 motions a day. You were taken into hospital, as you were very dehydrated. You then had to have a colonoscopy where they took parts of the tissue of your colon to look at under a microscope, which was so embarrassing for you.

After your hospital admission you were started on some medications, that you were told would help you recover from this bad episode. There was a steroid medication, and another one called mesalazine.

You then had to keep seeing doctors after that. They told you that you had something called “Crohn’s Disease” and that it was a condition where your digestive tract became inflamed, which is what had caused the bleeding and the ulcers. You were told that with medication it could be controlled, but that sometimes it may flare up similar to your recent hospital admission. Your doctor started you on this medication, Azathioprine, that you had to take every day.

You had a relapse of disease about six months after diagnosis. As a university student, you didn’t want to have to worry about taking medications and stopped taking your tablets. You also started smoking, and going out a lot more, binge drinking. This episode was similar to the first episode you had, with extreme pain, and never ending bloody diarrhoea. You were started on the steroid tablets and mesalazine again and recovered, but your consultant warned you that acting as you had could allow your disease to get out of control, and that you could end up with a stoma bag if it got too bad. This worried you and you have never smoked, or missed a tablet since.

Since then your disease has been relatively well controlled. You have been hospitalised only once since then, with another relapse, a year ago. Several smaller relapses have been treated with an ‘elemental diet’ where you are only allowed to drink this special solution to allow your intestines to recover.

Day-to-day, you aren’t affected too much but you do still get diarrhoea, sometimes with blood, which is embarrassing for you. You’ve started getting pains in your fingers, and they tend to be very stiff in the morning. You’ve been told that arthritis can be linked to Crohn’s so you think that this must be it. It’s like you’re getting old in your 20s!

ICE: At the moment, you feel alright with how things are going. The frequent outpatient appointments sometimes feel pointless, especially when you are doing well, but you do appreciate them if you’ve had a particularly rough few months. When you were first diagnosed, and around the time of your first relapse, you fell behind at university which resulted in you failing some exams, which you resented as you like to do well. As this is your last year of your PHD you’re worried that the Crohn’s could knock you out and sabotage your results.

You do expect that eventually you’ll stop being so lucky with your condition and will start to get worse. Your biggest fear is having a bag, and you aren’t sure how you’ll cope physically, or emotionally with this as you’re scared it will ruin your confidence, particularly with girls.

You like to keep things to yourself, and thus you don’t talk about your condition with anybody. Outside your family, only two of your friends know. You don’t like being different.

PMH: Before you were diagnosed you didn’t have any other medical problems

DH: Azathioprine 2.5mg/day You take an elemental formula when you’re having mild relapses

FH: Mother has rheumatoid arthritis

SH: You live on your own in a flat near the university where you study. You have quite a few friends, both from your undergraduate degree and from your PHD studies but you don’t want them to think that you’re weird for having a condition that makes you poo blood. You find it particularly hard to develop romantic relationships with girls because you worry about how they’ll perceive you when they “find out”. You’ve had a few on-off girlfriends over the years but nothing serious, but this is starting to get you down. After your rebellion with the cigarettes back in your undergrad, you haven’t touched a cigarette since. You drink alcohol, but only once or twice a month. Your parents are very supportive of you, but they live about a six-hour drive away, which makes things difficult.

The student should take a thorough history of Dom’s condition, and should be able to elicit the impact that it has had, and does have on his life, and explore his concerns about the future. An abdominal examination would be appropriate.

Differential Diagnosis: My differential diagnosis would include an inflammatory bowel disease, such as Crohn’s Disease or Ulcerative Colitis. Crohn’s disease is more likely, as Dom experienced symptoms indicating widespread involvement of the GI tract, including mouth ulceration and bloody diarrhoea. Ulcerative colitis only affects the distal GI tract.

Discussion Questions:

What are the types of inflammatory bowel disease? What are the main differences between them? What would be appropriate investigations to carry out in somebody presenting like Dom did initially? What are the management options for IBD? Which healthcare professionals could be involved in Dom’s care? What complications could affect Dom in the future? Name some of the extra-gastrointestinal manifestations of IBD.