Name: Ronald Wilson

DOB: DD/MM/YYYY

Age: 19

• You want to get back to your normal daily routine especially the university football team and not have to think about potentially being in pain -- you are very calm and respectful to the doctors

• I: You think it could be related to all the previous surgeries which you have had
• C: You are worried that you are developing Crohn's just like your father
• E: You would like to be referred to a specialist who will run specific tests

• You have been experiencing cramping abdominal pain over that last 3 months at least 3 times per week, which seems to unrelated to food or activities

Positive symptoms:

• Pain:

  • Average 3 times per week
  • Cramping pain
  • Pain comes on suddenly -- then comes and goes
  • No abdominal pain prior to 3 months
  • Diffuse/all over abdomen -- strongest around where you had your appendix removed
  • No radiation
  • Pain varies -- strongest 8/10
  • Pain strong enough to wake during the night frequently
  • Tried paracetamol/ibuprofen -- made no difference
  • No obvious association with food or activities
  • Pain slightly better after defecation
• Diarrhoea -- on and off past 2 months (did not think much of it, never had 'strong bowels)
• Stool normal colour
• Backpassage often painful on wiping with streaks of red blood on toilet paper
  • Assumed due to poor/cheap toilet paper quality

Negative symptoms:

• No feeling of incomplete bowel emptying
• No constipation
• No blood in stool
• No oral lesions
• No rashes/joint pain/eye pain/redness
• No red flag symptoms e.g. jaundice, fever, night sweats, weight loss, loss of appetite
• No other gastrointestinal or systemic symptoms e.g. dysphagia, nausea & vomiting, bloating, tiredness, palpitations, urinary symptoms

• Appendicitis 12y/o -- appendicectomy performed
• Pyloric stenosis 2 month old -- pyloromyotomy surgery
• Asthma
• Nil other medical history

• Blue inhaler -- ventolin (as needed)
• Brown inhaler -- beclomethasone (once daily)
• No other medications
• No known drug allergies

• Father developed Crohn's disease age 54
• Paternal and maternal grandfather died of bowel cancer
• Nil other family history

• Non-smoker
• Socially drink alcohol
• Caucasian ethnicity
• Occasional recreational drug use (1-2 per month) e.g. cocaine, MDMA
• Student -- arts and sciences
• Vegan diet
• Live in student accommodation
• Affecting participation in sports and social activities
• No recent travel