Case 2

1.         Define all unknown terms. 

The students were told to use any source necessary to define all unknown terms in the case. The following texts are required: Medical dictionary, Robbins pathology text, Bates' physical diagnosis test and Greene's Clinical Medicine("...is a work stimulated by and intended for medical students. It is primarily designed to help bridge the chasm between the basic science and the wards. The format identifies the problems eg. pruritus, cough ‑ that patients describe and helps the student move through the history, physical examination and laboratory data to arrive at a diagnosis,"). Harrison's and Cecil's textbooks of medicine are recommended. 

2.      What is the main clinical problem(s) - not the diagnosis? 

·        change in bowel habits

·        positive occult blood in stool

·        anemia 

3.         Develop a differential diagnosis for constipation. 

·        Diet deficient in fiber

·        Irritable bowel syndrome

·        Mechanical obstruction

·        Colon carcinoma

·        Chronic diverticulitis

·        Hernia/adhesions

·        Volvulus

·        Fecal impaction

·        Drugs: anticholinergics, antacids with calcium or aluminum

·        Depression

·        Metabolic conditions: hypothyrodism 

4.         What is the diagnosis? 

·        Adenocarcinoma of the colon

·        Metastatic carcinoma, liver

5.   Cite data which supports or refutes your diagnosis. 

This elderly woman, who presents with a change in bowel habits, possible weight loss,  anemia, occult blood in the stool and hepatomegaly, has an adenocarcinoma of the colon with possible liver metastases. She has no other apparent source of bleeding. 

The abdominal findings are not consistent with a (complete) bowel obstruction. The surgical scar is a coincidental finding. 

Much of the past medical history, review of symptoms and physical findings have little or no bearing on the case. Consistent with age of patient. 

6.   Explain the significance of the laboratory data in this case. What do you expect the liver scan  to show? 

Decreased Hb/Hct is consistent with anemia. The alkaline phosphatase and total bilirubin are slightly elevated suggesting some intrahepatic obstruction from metastases. The liver scan showed multiple filling defects consistent with metastases.

7.    What type of anemia would you expect in this patient? 

      Iron deficiency anemia; hypochromia, microcytosis. 

8.   What data in this case suggests malpractice? 

The patient was anemic 6 months prior to this visit. She should have been worked up for the cause of the anemia and not placed on an iron supplement.

9.   What if the patient was a 70 year old woman who presents with a chief complaint of having a large, bloody bowel movement? Earlier in the day, the patient experienced the urge to defecate and then passed a large quantity of blood. She had no nausea, vomiting, abdominal pain, tarry stool or  lightheadedness. Although she appeared pale in the ER, she was alert and talkative. Her pulse was  110/min and regular. Her blood pressure, in a supine position was 150/70 mm Hg which fell to 130/60 when she sat up. The examination of the abdomen revealed normal active bowel sounds and no tenderness, masses or organomegaly. Rectal exam revealed large external hemorrhoids but no masses. Stool was grossly bloody. The hematocrit was 27%, WBC was 10,500 cells/mm³ without a left shift. Platelets were 347,000/mm³. Prothrombin time was 10.2 seconds. BUN and creatinine were 12 mg/dL and  0.6 mg/dL respectively. The initial workup was negative for a specific bleeding site. During hospitalization the stool was negative for blood; however, she passed a bloody stool on the fourth hospital day.What is the clinical problem? Develop a differential diagnosis by listing diseases which may present with this problem, especially in an elderly person. What is your diagnosis? 

·        Hematochezia

·        Small volume hematochezia

·        anorectal disease

·        colitis (ischemic)

·        polyps or neoplasms

·        Large volume hematochezia

·        diverticulosis

·        arteriovenous malformations

·        Diagnosis: arteriovenous malformation

10.     Compare and contrast melena, hematochezia and occult blood in the stool. 

  Melena is a black, sticky, tarry, malodorous stool. This finding is compatible with GIT  bleeding, usually from the upper GI tract above the colon. Digestive enzymes act upon the blood to change the color and consistency.

Hematochezia is passage of bright red blood per rectum. Bleeding may occur from any point in the GI tract but generally indicates lower GI tract hemorrhage from the colon (or distal ileum). Occult blood in the stool can not be seen with the naked eye and requires a special test to confirm its presence. Bleeding may occur anywhere from the nasopharynx to anus.