ADMITTING

CONFERENCE Group 2
(Red-Indigo-Violet A)
 DIVISION OF WORK

Illness script + Approach to diagnosis- 2

[1-2]
History PE + additional questions + initial
impression- Done
Differential diagnosis - 10 [3-12]
Diagnostics - Impression - 7 [13-19]
Admitting orders - 7 [20-25]
69 y/o F
CC: Hematochezia
 01
Approach to a
patient with
Hematochezia
Cotter, T., Buckley, N. and Loftus, C., 2017. Approach to the Patient With Hematochezia. Mayo Clinic Proceedings, 92(5), pp.797-804.
Cotter, T., Buckley, N. and Loftus, C., 2017. Approach to the Patient With Hematochezia. Mayo Clinic Proceedings, 92(5), pp.797-804.
Cotter, T., Buckley, N. and Loftus, C., 2017. Approach to the Patient With Hematochezia. Mayo Clinic Proceedings, 92(5), pp.797-804.
 Common Causes of LGIB
Vascular Angiodysplasia
Hemorrhoids
Ischemic
Post-biopsy or polypectomy
Radiation-induced telangiectasia

Anatomic Diverticulosis

Inflammatory Infectious
Inflammatory bowel disease
Ulcer

Neoplastic Polyp
Carcinoma
10 Differential Diagnosis
● Colorectal CA
● Diverticular Bleed
● Ischemic Colitis
● Angiodysplasia
● Infectious Colitis
● Hemorrhoids
● Inflammatory bowel disease
● Colonic Polyps
● Peptic ulcer disease
● Gastric CA
 02
History and
Physical Exam
Questions
 History
Question Answer

Onset, duration, character of the stools, associated with pain when Intermittent bright
defecating (bristol stool chart, blood mixed/surrounding the red blood in the stool
after wiping for 3
stool/blood found on toilet paper or dripping, color of blood, volume years. Last bout
of blood), associated with pain when defecating (temporality? moderate amount
aggravating?) intermixed with stool

Crampy abdominal
What other symptoms are present in the patient? pain (occ diffuse occ
epigastric)
Slightly lightheaded

Yes. As stated above.

Previous episode of any GI bleeding?
 History
Losartan, aspilet at 80
Current medications the patient is taking? mg, atorvastatin
40 mg

Colon CA mother at 88
Family history of cancer, colorectal disease, cardiac disease,
years old. T2DM
hypertension, diabetes, blood disorders, renal disease father.

Variety of types of
Usual diet and recent food intake? veggies and meat.

History of previous hospital admissions, surgeries done, current

None
comorbidities or illnesses, or IBD in particular?
 History
Half pack per day
Current risk factors: Smoking and alcohol history since 18 years old; No
alcohol intake

Any invasive diagnostic procedure done recently? None

What are the relieving factors? None in particular

 Physical Exam
Question Answer
125/80. Her heart
1. Vital signs (BP, RR, PR, Temp) and anthropometrics (ht, wt, BMI)
beats RR 36.8 C, 22
Orthostatic hypotension per minutes.

Normal gait, pale

2. General appearance and skin inspection
palp. Conj.

(-) mass or
tenderness
3. Inspection and Digital Rectal Exam
bright red blood on
the examining finger

Globular, soft
4. Abdominal PE: IAPP

5. Chest PE (IPPA) Normal

 03
Differential
Diagnosis
10 Differential Diagnosis
● Colorectal CA
● Diverticular Bleed
● Ischemic Colitis
● Angiodysplasia
● Infectious Colitis
● Hemorrhoids
● Inflammatory bowel disease
● Colonic Polyps
● Peptic ulcer disease
● Gastric CA
 COLORECTAL CANCER
History Physical Examination
● Most common malignancy of the GI ● Blood in stool - may be bright, or dark
tract in the Philippines red, may also be occult
● Men = Women ● Chronic symptoms
● Age 50 = Average risk ● Narrow stools
● Family history of colorectal CA in 25% ● Hypochromic, microcytic anemia (IDA)
● Tenesmus ● Persistent abdominal pain
● Risk factors: ● Unexplained weight loss: 10 lbs in 6
○ Diet: animal fats, processed food, months
insulin resistance ● Cramping pain
○ FH: polyps ● Obstruction and perforation
○ IBD
○ Smoking and alcohol consumption
 DIVERTICULAR BLEEDING
History Physical Examination
● Signs and Symptoms ● Normotensive
○ Painless hematochezia, Self ● Severe bleeding
limiting ○ Tachycardic and hypotensive
○ Crampy abdominal pain, bloating, ○ Poor skin turgor, dry skin
○ Oliguria
urge to defecate
○ Altered level of consciousness
○ Some have massive, persistent ● Abdominal Examination
hematochezia with accompanying ○ Typically normal
hemodynamic instability, syncope, ○ Only some have tenderness upon
lightheadedness palpation
● Risk Factors ● DRE: bright red or dark blood streaked
○ >70 years stool
○ Diverticulosis
○ Obesity
 ANGIODYSPLASIA
History Physical Examination

● Older than 60 years ● Asymptomatic OR with mild-moderate

● History of end-stage renal disease, von occult GI bleeding without abdominal
Willebrand disease, aortic stenosis pain
● Prior antiplatelet or anticoagulant intake ● Signs and symptoms of anemia
○ Pallor
○ Fatigue
○ Weakness
○ Lightheadedness
● Systolic ejection murmur (if (+) aortic
stenosis)
 INFLAMMATORY BOWEL DISEASE
History Physical Examination

● Diarrhea ● Tender anal canal

● Hematochezia ● Blood on DRE
● Tenesmus ● Tenderness to palpation over colon
● Crampy abdominal pain ● Fever, tachycardia, pallor, Hypotension
● Chronic : weeks to months ● Muscle wasting, loss of subcutaneous fat
● Age of onset: 2nd-4th and 7th to 9th
decades
● Smoking
● Increased dietary intake of fats
 COLONIC POLYPS
History Physical Examination

● Common in ages >50 years old ● Distal rectal polyp detected by digital
● Usually asymptomatic rectal examination
● Clinical Manifestations ● Other findings are typically normal
- Hematochezia
- Change in bowel habits
- Diarrhea or constipation
- Mucus in stool
- Abdominal pain
● Risk factors:
- Consumption of animal fat (red meat,
processed meat)
- Smoking and alcohol consumption
- Obese
- Family history of colon polyps
 Diverticulitis
History PE
● Signs and Symptoms ● Low Grade Fever
○ LLQ pain / RLQ pain - constant and ● Hypotension and shock
present for several days ● Tender mass (20%)
○ Nausea, vomiting ● Localized guarding, rigidity, rebound
○ Constipation, diarrhea tenderness
● DRE: mass or tenderness
○ Urinary changes
● Risk Factors
○ ~63 y/o
 Colorectal CA
Colorectal CA - elderly

● Peak: 65-74yo; older age

● Risk factors:
○ Diet: animal fats, processed food, insulin resistance
○ FH: polyps
○ IBD
○ Smoking and alcohol consumption

SIGNS & SYMPTOMS:

● Change in bowel habits

● Low grade and recurrent bleeding
● R colon: unexplained iron deficiency anemia (raise suspicion for colorectal CA in >50yo and postmenopausal)
● L colon: abdominal pain, obstruction, perforation
● weight loss, fever, night sweats, fatigue, abdominal discomfort. If advanced colorectal CA: w/ palpable
abdominal mass and intestinal obstruction
 Diverticular Bleeding
● Most common cause of brisk ocult LGIB
● Ruptured diverticula due to the segmental weakness of the vasa recta
● Occurs primarily in the right colon 50-90%
● Signs and Symptoms
○ Painless hematochezia, Self limiting
○ Few abdominal symptoms
○ Some have massive, persistent hematochezia with accompanying
hemodynamic instability
● Risk Factors
○ >70 years
○ Diverticulosis
○ Obesity
● Diagnosis
○ Colonoscopy, nuclear scintigraphy, angiography
 ISCHEMIC COLITIS
History PE

● ●
 INFECTIOUS COLITIS
●
● Etiology: E. coli, Salmonella, Shigella, Campylobacter
● Source of infection: contaminated food or water
● Clinical Manifestations:
○ Gradual onset
○ Diarrhea
■ Sometimes bloody
○ Abdominal pain
○ Dehydration (in severe diarrhea)
○ Hyperactive bowel sounds
● Diagnostics
○ Fecalysis: (+) fecal leukocytes / fecal lactoferrin
○ Stool culture
○ Colonoscopy: rectal involvement, frequently widespread colitis
 INFECTIOUS COLITIS

History Physical Examination

● Common in developing countries with ● Low-grade fever
poor sanitation ● Dehydration (in severe diarrhea)
● Intake/exposure to contaminated food ● Hyperactive bowel sounds
or water ● Abdominal tenderness
● Sudden onset
● Diarrhea
○ Sometimes bloody
● Abdominal pain
● Low-grade fever
 HEMORRHOIDS

History PE
○ DRE : presence of hemorrhoids,
○ 45-65 years old blood on examining finger
○ Asymptomatic ○ Abdominal PE may be normal
○ Painless passage of bright red stool
○ Anal pruritus, anal pain
○ Risk factors:
■ Prolonged straining during
bowel movement
■ Chronic constipation
■ Low fiber diet
 PEPTIC ULCER DISEASE
History Physical Examination

● Character of pain: burning and gnawing; ● Often normal if mild PUD

“hunger-like”, epigastric or substernal, chronic ● If with perforation or massive bleeding:
● Gastric ulcer: pain precipitated by food; Hypotension
nausea and weight loss common Tachycardia
● Duodenal ulcer: pain occurs 90 mins to 3 hrs Fever
after meal; relieved by antacids or food; night Abdominal tenderness
distress common Muscle guarding / abdominal rigidity
● Penetrating ulcer: constant dyspepsia not Altered mental status
relieved by food or antacid; radiating to the
back
● Most common risk factors: H. pylori and
NSAIDs
● Other risk factors: smoking, alcohol
consumption, genetics
● Other features: belching, bloating, heartburn,
hematemesis, melena, hematochezia (in
massive amounts), early satiety, fatigue
● Responds to PPI
 Gastric CA
History
● Ingestion of high concentration on
nitrates found in dried and salted
foods.
● History of PUD.
● Upper abdominal discomfort
● Vague, postprandial fullness to
severe and steady pain.
● Weight loss, nausea and vomiting can
be observed in tumors that involve
the pylorus
● Dysphagia and early satiety in tumors
located at the cardia.
Physical Exam
● Palpable abdominal mass
● Palpable nodule in the periumbilical
region (Sister Mary Joseph Nodule)
● Patients may also present with
anemia (pale palpebral conjunctiva,
dry oral mucosa, pallor, tachycardia)
● Extensive metastases to the liver may
present with ascites.
Additional questions
Request for diagnostics
List of Ancillaries to do:
● Colonoscopy with tissue biopsy
● CBC
● Blood typing & crossmatching
● PT, PTT
● Serum Na, K
● BUN, Creatinine
● AST, ALT
● Lipid Profile
● FBS
● HbA1c
Top 3 Differentials
“Diagnosis”

Diagnosis
 04
Admitting
Orders
 ADMITTING ORDERS
69 y/o
CC: Hematochezia DOCTOR’S ORDERS

February 3, 2021 Admit the patient in the ward under the service of Dr. Kho
1:00PM Secure consent for admission.
Diagnosis: Lower Gastrointestinal Bleeding secondary to Colorectal CA
Place the patient on NPO 6-8 hours before colonoscopy. Diet as tolerated afterwards.
Activity as tolerated.
Insert IV line and infuse D5W- 0.9% Saline solution.
Hook to cardiac monitor and pulse oximeter.
Monitor
- VS every 4 hours and record
- Monitor I&O every shift and record
Watch out for seizures, arrhythmia, and congestion, worsening of hematochezia. Notify AMD
immediately.
Request for the following
- COVID-19 PCR, Chest X-ray, CBC with platelet count, Blood typing and cross matching,
Colonoscopy with tissue biopsy, PT and PTT, AST, ALT, Lipid profile, FBS, HbA1c
Therapeutics:
- Discontinue aspirin intake 7 days prior to colonoscopy.
- Discontinue losartan if blood pressure falls <120/80.
Refer to gastroenterology for colonoscopy
 ADMITTING ORDERS
69 y/o
CC: Hematochezia DOCTOR’S ORDERS

February 3, 2021 Admit the patient in the ICU under the service of Dr. Marcial.
Secure consent for admission.
1:00PM Diagnosis: Chronic hypovolemic hypernatremia secondary to severe dehydration due to osmotic diarrhea,
diuretics, and decreased oral Intake
Insert NGT
Diet: 1500 kcal, low salt diet (225g CHO, 57g CHON, 42g Fat).
Divide osterized feeding into 6 equal feedings with pre and post flushing of 50cc and 100cc in between
feeding. Aspirate first prior to each feeding. Hold feeding if aspirate is >200cc. Watch out for bloating and
vomiting.
Place the patient on bed rest.
Insert IV line and infuse 0.45 NaCl 1L at a rate of 120 ml/hr.
Hook to cardiac monitor and pulse oximeter.
Insert foley catheter and hook to hospicare bag.
Monitor
- VS every hour and record
- Accurate I&O every hour and record
- Serum Na 4 hours after the first extraction
- GCS score
- Frequency, amount, and character of stool
Watch out for seizures, arrhythmia, and congestion. Notify AMD immediately.
Request for COVID-19 PCR, ECG, portable chest x-ray, ABG, CBG, BUN, Serum Creatinine, and stool exam.
Refer accordingly.
THANK YOU!