Mrs. C was seen at the surgery on 03/09/09 complaining of changes in bowel habits. She noticed her bowel habits had become more erratic over the last few months, where she had episodes of diarrhoea alternating with constipation. In the past, she used to have problems with chronic constipation. She also noticed bright red blood in her stools which normally came towards the end of defeacation. There was no mucus in her stools, malaena, pain noted on defeacation. She complained of left iliac fossa pain which came intermittently and mostly relieved upon defeacation. Despite having tenesmus and increasingly aware of passing flatus, there was no faecal incontinence. She agreed that her haemorrhoids had become more problematic recently. But, did not notice any peri-anal ulceration.
She denied any weight loss, changes in appetite, indigestion, heartburn, haematemesis or nausea/ vomiting. She did not complain of urinary symptoms (e.g. dysuria, haematuria, frequency, urgency, incontinence, etc).
She had some problems with stiff joints mainly in her wrists, hands, knees and ankles, which were worse in the morning. She has a history of rheumatoid arthritis. Occasionally, her joints would flare up and become swollen, erythematous and painful. At present, she did not complain of any joint problems as the anti-rheumatoid medications and analgesics provided symptomatic relief and remission of her RA. However, the co-codamol does not help with her constipation.
NKDA
Medication
Dosage
Frequency
Movicol
Daily
Lactulose
10ml
BD
Leflunamide
10mg
OD
Hydroxychloroquine
200mg
OD
Co-codamol
8/500mg
BD
Daktacort cream
Omeprazole
20mg
OD
Folic acid
5mg
OD
Salbutamol inhaler
100mg
2puffs BD
Sulfasalazine
500mg
OD
Proctosedyl suppositories
No significant family history.
Lives with her family. Does not smoke. Drinks occasionally.
Neurological
None to note.
Cardiovascular
None to note.
Respiratory
None to note.
Gastrointestinal
See above
Genitourinary
None to note. No dysuria, polyuria or haematuria.
Haematological
None to note. No fevers or rigors
Musculoskeletal
See above.
Endocrine
None to note. No polydipsia or polyuria.
Reproductive
No sexual dysfunction.
Skin
Hands and nails
Eyes
Mouth
Chest
Abdomen
No jaundice/ skin-pallor
No generalised skin pigmentation of haemosiderin
No palmar erythema / Non-pallor palmar creases
Presence of dupuytren’s contracture on both hands
No asterixis
No finger clubbing, leuconychia, koilonychia
Non jaundiced eyes
No Kayser-Fleischer rings (brownish green rings)
Presence of corneal arcus
Good oral hygiene
No glossitis or angular stomatitis or ulceration
No spider naevi
No scars but striae present
No visible engorged veins or visible peristalsis or arterial pulsation
No caput medusae/ No Cullen’s (blue discolouration of umbilicus)/ No Grey-Turner’s sign (blue discolouration of flank)
Symmetrical movement of the abdomen with respiration
Neck
Gentle palpation
Deep palpation
Liver
Spleen
Kidney
No enlarged supraclavicular lymph node
No tenderness/ guarding
No abnormal masses or organomegaly
Soft, regular liver edge, not enlarged or tender, non-pulsatile