DOORWAY INFORMATION
Opening Scenario
Kenneth Klein, a 55-year-old male, comes to the clinic complaining of blood in his stool.
Vital Signs
BP: 130/80 mm Hg Temp: 98.5°F (36.9°C)
RR: 16/minute HR: 76/minute, regular
Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
Checklist/SP Sheet
Patient Description
Patient is a 55 yo M, married with 2 children.
Notes for the SP
If colonoscopy is mentioned by the examinee, ask, “What does that word mean?”
Challenging Questions to Ask
“My father had colon cancer. Could I have it too?”
Sample Examinee Response
“It is a possibility. Tell me more about the symptoms you’re having that concern you with regard to cancer.”
Examinee Checklist
Building the Doctor-Patient Relationship Entrance
□ Examinee knocked on the door before entering.
□ Examinee introduced self by name.
□ Examinee identified his/her role or position.
□ Examinee correctly used patient’s name.
□ Examinee made eye contact with the SP.
Reflective Listening
□ Examinee asked an open-ended question and actively listened to the response.
□ Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
□ Examinee summarized the SP’s concerns, often using the SP’s own words.
Information Gathering
□ Examinee elicited data efficiently and accurately.
Connecting with the Patient
□ Examinee recognized the SP’s emotions and responded with PEARLS.
Physical Examination
□ Examinee washed his/her hands.
□ Examinee asked permission to start the exam.
□ Examinee used respectful draping.
□ Examinee did not repeat painful maneuvers.
Closure
□ Examinee discussed initial diagnostic impressions.
□ Examinee discussed initial management plans:
□ Follow-up tests: Examinee mentioned the need for a rectal exam.
□ Examinee asked if the SP had any other questions or concerns.
Sample Closure
Mr. Klein, the symptoms you describe may be due to readily treatable problems, such as hemorrhoids, an infection in your colon, or diverticulosis. However, they may also be a sign of more serious disease, such as colorectal cancer. It is crucial that we run some blood tests, a stool exam, and probably a colonoscopy, which involves looking at your colon through a thin tube that contains a camera. I will also need to perform a rectal exam today. Once we make a diagnosis, we should be able to treat your problem. Do you have any questions for me?
History
HPI: 55 yo M c/o bright red blood per rectum.
■ History of constipation 6 months ago, 2 bowel movements a week.
■ 1 month ago noticed blood mixed with stool with each bowel movement.
■ 2 days ago, tenesmus and watery brown diarrhea mixed with blood.
■ 10-lb weight loss in 6 months despite good appetite.
■ Diet of junk food and no vegetables.
■ No urgency, mucus in stool, or pain with defecation.
■ Denies fevers, chills, nausea, vomiting, abdominal pain, recent history of travel, or contact with ill persons.
ROS: Negative except as above.
Allergies: NKDA.
Medications: Used to take many laxatives (bisacodyl), but stopped after the onset of diarrhea 2 days ago.
PMH: Bronchitis 3 weeks ago, treated with amoxicillin.
PSH: Hemorrhoids resected 4 years ago.
SH: No smoking, no EtOH, no illicit drugs. Sexually active with wife only.
FH: Father died of colon cancer at age 55.
Physical Examination
Patient is in no acute distress.
VS: WNL.
Chest: Clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nondistended, nontender,
BS, no hepatosplenomegaly
Differential Diagnosis
CASE DISCUSSION
Patient Note Differential Diagnoses
■ Colorectal cancer: A positive family history coupled with the presence of blood in the stool, a change in bowel habits, and weight loss is consistent with this diagnosis. A rectal exam with stool tested for occult blood should be sent to start the necessary workup.
■ Hemorrhoids: Recurrent hemorrhoids may explain the patient’s hematochezia, but more typical findings in hemorrhoids are fresh blood on the toilet paper or in the toilet bowl.
■ Pseudomembranous (C difficile) colitis: It is important to ask all patients with acute diarrhea about recent antibiotic exposure, as symptoms of antibiotic-associated colitis may be delayed for up to 6-8 weeks. However, stool rarely contains gross blood. The absence of fever and lower abdominal cramping also makes this diagnosis (and other forms of infectious colitis) less likely.
Additional Differential Diagnoses
■ Diverticulosis: This is the most common cause of major lower GI bleeding, but it usually presents with larger- volume bleeds occurring in discrete, self-limited episodes.
■ Angiodysplasia: This is another common cause of lower GI tract bleeding, but as with diverticular disease, it cannot explain the other features of this patient’s presentation.
■ Ulcerative colitis: Although the patient has chronic constipation, the absence of abdominal pain and the recent onset of diarrhea and tenesmus make inflammatory bowel disease a less likely etiology for this patient’s month-long hematochezia.
Diagnostic Workup
■ Rectal exam, stool for occult blood: Useful for detecting masses and hemorrhoids. Always test for occult blood in stool, especially in a patient complaining of visible blood with each bowel movement.
■ Colonoscopy: A screening colonoscopy should have been offered to the patient at age 45 (10 years before the age at which a first-degree family member was first diagnosed). It should be the initial test performed in patients older than 40 years of age presenting with hematochezia.
■ Stool for C difficile PCR: A stool C difficile toxin assay has low sensitivity and has been replaced at most institutions with PCR. The C difficile PCR test has a turnaround time of two hours with a sensitivity and specificity higher than 97%.
■ Fecal leukocytes: Usually present in invasive bacterial infection and in inflammatory bowel disease. Variably present in C difficile colitis.
■ CBC: To investigate anemia. Leukocytosis could also suggest infection or inflammatory bowel disease.
■ Anoscopy: Can identify bleeding internal hemorrhoids, rectal ulcers, and traumatic lesions.
■ Flexible proctosigmoidoscopy: If nondiagnostic, follow up with a barium enema or a colonoscopy.
■ Double-contrast (air contrast) barium enema: Not as accurate as colonoscopy for the diagnosis of polyps and cancer, and cannot diagnose angiodysplasia. Used primarily when colonoscopy is unavailable or contraindicated.
■ CT—abdomen/pelvis: Contrast-enhanced exams can detect diverticulosis or masses but generally are not useful in the evaluation of GI bleeding.