Key History
Melena vs. bright red blood; amount, duration; associated symptoms (constitutional, abdominal or rectal pain, tenesmus, constipation/diarrhea); menstrual cycle; trauma; history of similar symptoms; prior colonoscopy; medications (especially blood thinners); history of easy bleeding or atherosclerotic vascular disease, renal disease, aortic valve disease, liver disease, alcoholism, or abdominal aortic aneurysm repair; family history of colon cancer.
Key Physical Exam
Vital signs ± orthostatics; abdominal and rectal exams.
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Presentation |
Differential |
Workup |
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■ 67 yo M presents with blood in his stool, weight loss, and constipation. He has a family history of colon cancer. |
Colorectal cancer Anal fissure Hemorrhoids Diverticulosis Ischemic bowel disease Angiodysplasia Upper GI bleeding Inflammatory bowel disease |
Rectal exam CBC AST/ALT/bilirubin/ alkaline phosphatase INR Colonoscopy CEA CT—abdomen/pelvis |
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■ 33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and tenesmus for several months. |
Ulcerative colitis Crohn’s disease Proctitis Anal fissure Hemorrhoids Diverticulosis Dysentery |
Rectal exam CBC PT/PTT Colonoscopy CT—abdomen/pelvis |
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■ 58 yo M presents with painless bright red blood per rectum and chronic constipation. He consumes a low-fiber diet. |
Diverticulosis Anal fissure Hemorrhoids Angiodysplasia Colorectal cancer |
Rectal exam CBC, type and cross PT/PTT Electrolytes Colonoscopy Tagged RBC scan CT—abdomen/pelvis |
Key History
Amount, duration, ± clots; associated symptoms (constitutional, renal colic, dysuria, irritative voiding symptoms); point along the stream (initial vs. terminal vs. throughout); medications; history of vigorous exercise, trauma, smoking, stones, cancer, or easy bleeding; skin bruising (purpura).
HEMATURIA (cant'd)
Key Physical Exam
Vital signs; lymph nodes; abdominal exam; genitourinary and rectal exams; extremities.
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Presentation |
Differential |
Workup |
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■ 65 yo M presents with painless hematuria. He is a heavy smoker and works as a painter. |
Bladder cancer Renal cell carcinoma Nephrolithiasis Acute glomerulonephritis Prostate cancer Coagulation disorder (ie, factor VIII antibodies) |
Genitourinary exam UA, urine cytology BUN/Cr PSA CBC PT/PTT Cystoscopy U/S—renal/bladder CT—abdomen/pelvis Prostate biopsy |
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■ 35 yo M presents with painless hematuria. He has a family history of kidney disease. |
Polycystic kidney disease Nephrolithiasis Acute glomerulonephritis (eg, IgA nephropathy) UTI Coagulation disorder Bladder cancer |
Genitourinary exam UA, urine cytology BUN/Cr PSA CBC PT/PTT U/S—renal CT—abdomen/pelvis |
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■ 55 yo M presents with flank pain and blood in his urine without dysuria. He has experienced weight loss and fever over the past 2 months. Exam reveals a flank mass. |
Renal cell carcinoma Bladder cancer Nephrolithiasis Acute glomerulonephritis Pyelonephritis Prostate cancer |
Genitourinary, rectal exams UA, urine cytology BUN/Cr PSA CBC PT/PTT U/S—renal CT—abdomen/pelvis Cystoscopy |
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