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  • Normal practice must include noting examination findings etc, so that you don't get sued.
  • PR bleed
    • Send for colonoscopy (NB: occult blood test is only for asymptomatic patient)
    • PR exam of male: normal prostate: median sulcus and two symmetrical lobes (firm but not hard, spongey). BPH: larger, but anatomy is maintained. CA: irregular, nodularities, anatomy distorted. Rectum is supposed to have supple walls to dilate. Loss of rectal compliance (e.g. after radiotherapy) --> stiff and fecal urgency, should feel a large space. Laterally you should feel pelvic sidewall. Posteriorly you should feel the sacral wall or the coccyx (can diagnose coccydenia?)
      • Pathology takes up space: not indentable, not mobile. Need to work out if it's from mucosa or from deep. Surface irregular = mucosa. Surface smooth = beneath mucosa
    • PR exam of female: anteriorly, feel the cervix (points backwards)
      • Sometimes a large anterior mass on PR exam can be tampon (ask about which part of the cycle)
  • Diagnosis of depression - rule out organicity first
    • GP's job = paediatrics, ENT and mood disorder
    • Iron deficiency anaemia >40 years = occult bleeding unless proven otherwise. So do colonoscopy.
  • Questions for the patient
    • Colour: 'bright red like cut arm', or 'tarry black' (malena), or 'burgundy' (in between)
    • How often is bleeding? Before, with or after defecation.
    • Is it admixed (higher lesion) or coating the stool (pelvic floor)
    • Amount/site: on toilet paper?
    • Pain: painful rectal bleed: 1) anal fissure (tear in ectoderm that causes painful anal sphincter spasm); pain after defecation [give rectogesic or botox] [most common] 2) anal cancer (malignancy of anus that grows into the lumen)
      • NB: most haemorrhoids are not painful, unless haemorrhoid thromboses or ulcerates. Haemorrhoid = painless bleed
  • Scoping is expensive: 800-900 per time;
    • Side effects of scope
      • Missed pathology: 1-2% of the time
      • Irritable bowel syndrome, wash out the gut flora and distend abdomen with CO2
      • Cut polyp out, bleeding: 1/500
      • Perforation: 1/2000
  • Delay in diagnosis: From a cutaneous/mucosa GI cancer, the prognosis drops off 0.5-1% per week (5 year survival rate)
    • Extrapolated back based on stage
      • Drive is that between diagnosis and intervention for malignancy is 2 weeks to minimise this
  • Dr Black didn't do what his peer group would have done
    • Also you should apologise if you've made mistakes
  • FOBT
    • Dietary restrictions: no red meat or certain vegetables
    • A couple of samples on plastic, then send out
    • Uptake percentage is not good - 40-50%
      • Positive result: alert GP and patient
  • Screening - study the criteria from SH
    • Asymptomatic population
    • Reasonable sensitivity
    • Must be that early treatment must give you a better prognosis
    • Must exist a precursor form of the disease
    • Cost effective
  • FOBT+, 2/3 of them you'll find pathology in the bowel on colonoscopy
    • Chance of colon cancer in this case is 10%
  • The point of screens
    • Economically proven
    • Improve survival
  • Other screens
    • Mammograms
    • Pap smears
    • Newborn screening: galactosemia, PKU, cystic fibrosis etc
  • Public endoscopy lists can be terribly long
  • Low rectal cancer in a young woman
    • Low rectal cancer invading toward the anus --> need abdominoperoneal resection, then radiotherapy and infertility
      • So rectal exam can save a lot of time before colonoscopy: rectal CA can be detected on rectal exam
    • Long waiting list
    • Staging rectal cancer: use MRI; using TNM status
    • With nodes +, you need radiotherapy. This results in infertility.
  • Raised urea with normal creatinine - 1) dehydration (eg. if fasting before the bloods) 2) bleeding and protein load in gut
  • Normal LFTs doesn't mean no liver metastases
    • But with normal LFTs you can't have a liver packed with mets
  • DDx for microcytic anaemia: iron deficiency, occult bleed, thalassemia trait (Mediterraneans)
  • Relevant FHx questions: GIT cancers and age of onset
  • Amsterdam criteria: 3 patients in a family spread out over 2 generations, one under 50 etc
    • Alerts you to HNPCC
    • Also includes urinary and uterine cancers
  • HNPCC still forms polyps, but not the mass of polyps that FAP forms
  • Steps: 1) colonoscopy 2) CT scan if positive
  • Diet: eat less processed meat. Don't eat charred meat.
  • Chemotherapy in colorectal
    • Nodes + or mets +
    • If you've resected it all and it's nodes -, you don't give chemotherapy
  • NOTE: all the parts of the history that need to be included in PR bleed/anaemia
  • Regular colonoscopies for:
    • Worried, have a symptom
    • Family history
  • Colon cancer occurs in 1/20 people, not worth it for society to scope everyone
  • Result of suing: money + apologise
    • Apology does not confer guilt - recognition of patient's suffering and expression of empathy. Professional reassurance that you will be of ongoing assistance to the patient. Don't wash your dirty laundry with them. Discuss teamwork errors in other meetings with your team, not in front of patient.
  • Doctor's job: discuss the medical issues, what you did + didn't do, and apologise