YANO, CASEY RAE T.

Block 6
Department of Surgery
Facilitator: Dr. Navarro

Informant: Patient Date: February 6, 2023

% Reliability: 95% Time: 4:00 PM

J.P., 68 years old, male, married, Filipino, Roman Catholic, retired mining engineer, currently
living in Lapu-lapu City, Cebu, was admitted for the first time on February 2, 2023 at UCMed due
to exertional dyspnea.

Chief Complaint: Exertional dyspnea

Past Medical History

Patient claims to have complete childhood immunizations from the Barangay Health
Center. He had a history of measles and mumps in Elementary both of which were
uncomplicated. No history of chicken pox nor asthma. Patient was diagnosed with hypertension
in 2005. His maintenance medication includes Losartan K & Amlodipine besilate (Amlife) 10 mg
taken once a day, with good compliance. His usual BP is 110/70 and highest BP is 130/90.
Patient also had a history of slipped disc while playing basketball last 2004. He sought
consultation and was suggested surgery, but did not comply. He relied on traditional medicines
like herbal topicals and had massages from his helper. He had difficulty mobilizing and walked
only with a cane for 3 months but currently does not experience any lower back pain or difficulty
in movement. Last 2018, patient was diagnosed with UTI secondary to kidney stones. An
incidental finding includes enlarged prostate. Patient took unrecalled medications for his kidney
stones and prostate enlargement, with poor compliance, for 3 months.However, he claims that
he is not symptomatic anymore. Patient was also admitted last 2006 in Chong Hua Hospital due
to blurring of vision. No surgical procedures were done and the patient claims he was only
admitted for monitoring. Patient cannot recall diagnosis and medications given. Patient was
discharged after 2 days. Patient has annual check-up. Laboratories usually ordered are claimed
to be complete with unremarkable findings. No surgical nor psychiatric history.

Family History
Patient’s birth rank is 5/7. Both his parents have died in their 70s due to old age. They
were both public servants, His mother was a Barangay Captain and His father was a City
councilor. Mother was known to have high blood sugar but was not diagnosed nor managed.
Heredofamilial disease includes Thyroid Disorders on the paternal side. He has 6 other siblings.
Their eldest died in his 30s due to a vehicular accident. One of his sis sisters has Diabetes
Mellitus. He has 3 children, ages ranging from 29-32 years old. All are healthy with no known
illnesses.
Personal and Social History
Patient is a BS Mining Engineering graduate. He has been working as mining engineer
in Surigao for 30 years in Surigao City and has recently retired but still works as a consultant
occasionally. He lives in a concrete house with his wife and son. Patient was an occasional
alcoholic beverage drinker but stopped at the age of 60. He is a non-smoker and claims no
history of illicit drug use. His usual diet consists of fish, chicken, rice, and vegetables which are
usually prepared by his wife. He consumes approximately 8 glasses of purified drinking water
daily. He has no voiding problems and has a regular daily bowel movement. Patient sleeps
approximately 8 hours a day from 7:30 pm to 3:30 am. Exercise includes basketball, but was
stopped due to old age, hand grippers, and walking around his neighborhood almost everyday.
Patient claims to be still sexually active with his wife and had a total of 2 sexual partners in his
lifetime. No contraceptives use. No recent travel history.

History of Present Illness

30 days PTA, patient had a sudden onset of dyspnea upon walking for at least 3 meters
on a flat plane. This was noted while the patient was walking around the house. Relieving
factors includes rest like sitting down. No associated headache, fever, cough, vertigo, , fatigue,
nausea, chest pain nor orthopnea. Patient condition was tolerated and no consultation was
done.

5 days PTA, patient’s dyspnea persisted, and was still noted to be aggravated by
exertion and relieved by rest. Persistence of dyspnea prompted the patient to seek consult at a
private clinic in Surigao. Laboratories taken include a complete blood count, renal function test,
liver function test, lipid panel, fasting blood sugar (FBS), HbA1c, Total PSA, abdominal
ultrasound, prothrombin time, and NT-proBNP. Test results showed that the patient had
anemia, with decreased RBC, hemoglobin (7.1 g/dL), hematocrit, MCV, MCH, and MCHC. Other
laboratory test results include: elevated basophils and platelets, hyperkalemia (5.3 mmol/L), low
HDL cholesterol, elevated FBS, elevated NT-proBNP, and elevated PSA (5.56 ug/L). All other
test results were unremarkable. Due to his laboratory test results, patient was advised to seek
further evaluation of his condition. He was referred to UCMed due to the unavailability of
laboratory procedures in Surigao. No medications were taken by the patient.

1 day PTA, patient’s exertional dyspnea persisted. No associated symptoms like fever,
cough, chest pain, bloody stool or hematemesis were noted. Patient sought consult at a private
clinic in UCMed for further work-up on his condition. Upon evaluation of the patient and his
laboratory findings 5 days PTA, patient was then advised to seek admission to further
evaluation.

On the day of admission, patient’s dyspnea persisted, which was still aggravated by
exertion and relieved by rest. No associated fever, cough, bloody stools or chest pain were
noted. Persistence of dyspnea, in addition to the advice to have further evaluation done for his
condition, prompted the patient to seek admission.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No weight loss, sweats, and fatigue. No fever and chills.
SKIN: No rashes and itching.
HEENT: Eyes: Wears glasses. Has ambylopia. Anicteric sclerae; pinkish palpebral conjunctivae
Ears: no gross deformities, no tenderness on manipulation. No tinnitus. Throat: No sore throat.
CARDIOVASCULAR: No chest pain, discomfort and palpitations. No edema.
RESPIRATORY: Has shortness of breath. No cough and hemoptysis.
GASTROINTESTINAL: No anorexia. No nausea, vomiting, or diarrhea. No abdominal pain, no
blood in the stool.
GENITOURINARY: No dysuria, no polyuria, no nocturia.
NEUROLOGICAL: No headache and dizziness. No paralysis, ataxia, numbness or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle pain, joint pain or stiffness.
HEMATOLOGIC: Has anemia, bleeding, bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No excessive sweating, cold or heat intolerance. No polyuria or
polydipsia.
ALLERGIES: No history of asthma, rhinitis, hives or eczema. No allergies to food and
medication.

Physical Exam:

General Survey: Examined conscious, coherent relaxed patient, not in respiratory distress with
the following vital signs:

BP: 130/100mmHg (left arm, sitting) Wt: 60.7 kg

HR: 88 beats/min Ht: 165 cm
RR: 20 cycles/min BMI: 22.3 (normal)
Temp: 35.6 C (axillary) O2 Sat: 96% at room air

Skin: Skin is dry, warm, and smooth to touch, with good skin turgor and mobility. No lesions are
seen. No rashes, petechiae, ecchymoses, discolorations or jaundice. No cyanosis or clubbing in
nails.

HEENT:
Head: Normocephalic, no tenderness
Eyes: Has Pterygium both eyes, L @ 9 o’clock R @ 9 o’clock; anicteric sclerae; pinkish
palpebral conjunctivae
Fundoscopy: (+) distinct disc margins; no arterial narrowing, A-V nicking, exudates, or
hemorrhages
Ears: no gross deformities, no tenderness on manipulation
Otoscopy: no impacted cerumen, pearly gray tympanic membrane which is not bulging or
retracted, each ear
Nose & Sinuses: Turbinates not inflamed, septum at midline, no tenderness over sinuses, good
illumination over paranasal sinuses
Mouth & Throat: Moist lips and oral mucosa, uvula at midline, tongue at midline on protrusion
Neck: no nuchal rigidity, trachea at midline, no palpable masses; Thyroid gland and salivary
glands are not enlarged; no bruit over carotid arteries; no venous enlargement

Cardiovascular: Adynamic precordium; 2 cm, brisk and forceful apical impulse palpable over
5th left intercostal space, midclavicular line; no thrills or heaves; cardiac area of dullness not
enlarged, regular rhythm, distinct S1 and S2, no murmur

Chest and Lungs: Thorax is symmetric with good expansion. Lungs resonant. No rales or
crackles. Diaphragm descend 4 cm bilaterally.

Breast and Axilla: Breast is flat and symmetrical. Nipples are brown, symmetrical and without
rashes, ulcerations nor discharge. No palpable masses. Axilla is smooth. No palpable lymph
nodes on both axillae.

Abdomen: Abdomen is symmetrical and round, with normoactive bowel sounds at 10

clicks/min. Presence clean dressing post appendectomy excision site on hypogastric area.
Generally tympanitic with dullness over the liver. Liver span 5cm at MSL and 7cm at right MCL.
Has direct tenderness over the epigastric area radiating to the RUQ and the back below the
shoulder blades. No rebound tenderness No palpable masses. No hepatomegaly no
splenomegaly. No costovertebral angle tenderness.

Genito-urinary: Not assessed

Rectum & Anus: Not assessed

Extremities: no deformities, no edema, no limitation of movements, strong and bounding

peripheral pulses (bilateral femoral and dorsalis pedis arteries), CRT <2 secs

Neurologic Exam
Mental Status Exam: Patient is awake, conscious, active, and cooperative. He is oriented to
person, place, and time. Recent and remote memory are both intact. Speech is fluent and words
are clear. Thought process, content, and insight are all intact.

Cerebral:
Awake,conscious and coherent, appropriate responses to questions and commands, no
aphasia, no right-to-left confusion, no apraxia

Cranial nerves:
CN 1: Intact sense of smell in both nostrils
CN 2, 3: Visual acuity good, pupils equal, reactive to light (direct & consensual) and
accommodation on each eye
CN 3, 4, 6: Horizontal nystagmus on lateral gaze. Incomplete left eye adduction by Finger
Following test
CN 5: (+) corneal reflex both direct and consensual
CN 7: No facial asymmetry; taste in anterior ⅔ of tongue intact
CN 8: intact by Spoken Voice Test
CN 9,10: Positive (+) gag reflex and swallowing reflex, uvula and soft palate at midline
CN 11: Able to shrug and turn head against resistance
CN 12: tongue at midline at rest and protrusion

Cerebellar:
Rapid alternating movements smooth and intact. Finger-to-nose intact on both sides.
Movements are smooth and accurate.

Sensory: Pinprick, temperature, light touch, position and vibration sense intact in both upper
and lower extremities

Motor: Good muscle bulk and tone, without atrophy. Muscle strength 5/5 throughout on
both sides. Full range of motion in all extremities and joints.

5/5 5/5

5/5 5/5

Reflexes:

Primary Impression: Anemia Secondary to Occult Gastrointestinal Hemorrhage

YANO, CASEY RAE T. Block 6
Department of Surgery
Facilitator: Dr. Navarro

CLINICAL FORMULATION

My primary impression for this 68-year-old male presenting with exertional dyspnea is
Anemia Secondary to Occult Gastrointestinal Hemorrhage. We considered this as the primary
impression since the patient’s chief complaint is exertional dyspnea. Anemia may cause the
sensation of breathlessness or labored breathing during exercise, ultimately due to decreased
availability of oxygen to the working muscles. Patient’s laboratory results prior to admission
showed decreased cell count, very low hemoglobin, low MCV, low MCH, and increased platelet
count. With iron deficiency anemia, red blood cells are smaller and paler in color than normal.
Low hemoglobin (Hg), low hematocrit (Hct), and low mean cellular volume (MCV) also occur.
Mild thrombocytosis is also commonly seen in patients with iron deficiency anemia. Patient also
showed a high NT proBNP. In a recent study, plasma BNP is a useful marker for the adverse
effects of anemia. Occult gastrointestinal bleeding, defined as bleeding that is unknown to the
patient, is the most common form of gastrointestinal bleeding and can be caused by virtually
any lesion in the gastrointestinal tract. Patients with occult gastrointestinal bleeding include
those with fecal occult blood and iron-deficiency anemia (IDA). In men and postmenopausal
women, IDA should be considered to be the result of gastrointestinal bleeding until proven
otherwise. Indeed, the possibility of gastrointestinal tract malignancy in these patients means
that gastrointestinal evaluation is nearly always indicated. Obscure gastrointestinal bleeding is
defined as obvious bleeding from a difficult to identify source and is always recurrent. This form
of bleeding accounts for approximately 5% of all cases of clinically evident gastrointestinal
bleeding and is most commonly caused by bleeding from the small intestine.

Differential Diagnosis

1. Congestive Heart Failure

Congestive heart failure can be ruled in this patient because of his history of
hypertension and exertional dyspnea. The cardinal symptoms of HF are fatigue and shortness
of breath. In the early stages of HF, dyspnea is observed only during exertion; however, as the
disease progresses, dyspnea occurs with less strenuous activity, and it ultimately may occur
even at rest. However, this can be ruled out because he has no history of orthopnea, cyanosis,
signs of pulmonary edema like rale, hepatomegaly, ascites nor peripheral edema.

2. Pulmonary Embolism
This can be ruled in since the patient is hypertensive, presenting with exertional
dyspnea. The most common symptoms for pulmonary embolism are sudden shortness of breath
& chest pain. However, each person may experience symptoms differently. Certain medical
conditions, such as heart failure, chronic obstructive pulmonary disease (COPD), high blood
pressure, stroke, and inflammatory bowel disease and Older age can predispose to pulmonary
embolism. Thus, we can rule this out because he had no history of surgery nor trauma, drug
abuse, warfarin use, nor cough.

3. Anemia of Chronic Disease t/c Cancer

This can be ruled in because of the patient’s age, history of weight loss, exertional
dyspnea possibly due to the patient’s anemia which revealed a microcytic hypochromic type.
The anemia of chronic disease is a multifactorial anemia. Diagnosis generally requires the
presence of a chronic inflammatory condition, such as infection, autoimmune disease, kidney
disease, or cancer. It is characterized by a microcytic or normocytic anemia and low reticulocyte
count. Worldwide, the anemia of chronic disease is the 2nd most common anemia Three
pathophysiologic mechanisms have been identified. First is slightly shortened RBC survival,
thought to be due to increased hemophagocytosis by macrophages, occurs in patients with
inflammatory diseases. Second, Erythropoiesis is impaired because of decreases in both
erythropoietin (EPO) production and marrow responsiveness to EPO. Third, Iron metabolism is
altered due to an increase in hepcidin, which inhibits iron absorption and recycling, leading to
iron sequestration. However, this can be ruled out because he has no palpable masses,
enlarged lymph nodes, family history of cancer and did not experience fatigue.

Diagnostic Management
Definitive Diagnostic:
1. Bidirectional Endoscopy - Initial tests of choice for investigation of occult blood loss.
Bidirectional endoscopy refers to an investigative approach where colonoscopy and
upper endoscopy are performed in sequence and in temporal relationship to the finding
of occult bleeding.

Supportive Diagnostic:

1. Fecal Occult Blood Test- recommended for colorectal cancer screening beginning at age
50 in average risk adults.
2. Chest Xray - Rule out Pleural Effusion or cardiac problems
3. CBC - elevated WBC count may occur in Diverticulosis. Hematocrit may drop following
significant acute or chronic blood loss.

THERAPEUTIC PLAN
Definitive Management:
Adequate volume resuscitation of the patient can be used to manage this patient to
correct his iron-deficiency anemia, especially because his anemia is symptomatic. Transfusion
with packed RBC can also be done if hemoglobin falls to < 7 g/dL. It is also important to identify
the source of hemorrhage so that interventions can be done to stop the bleeding. If bleeding
persists despite medical interventions, surgical management can be considered. A segmental
resection may be performed if the source of bleeding is identified. If no source of bleeding is
identified, a blind subtotal colectomy may be required if the patient is hemodynamically unstable
with ongoing colonic hemorrhage of an unknown source.

Supportive Management:
1. Inform the patient about the procedures needed to evaluate his symptomatic
anemia, such as a search for the source of bleeding. Inform him of the need of an
upper endoscopy to look upper GI bleeds, and a colonoscopy to look for sources
of lower GI bleeds, including its possible complications.
2. Ask and obtain a signed consent form for the procedures.
3. Place the patient on NPO 6-8 hours before the procedure.
4. Prepare the patient for colonoscopy with complete oral bowel preparations.
5. Establish an IV line for intravenous fluids. Start infusion of D5W 1L at a rate of
100 cc/h.
6. Monitor patient’s vital signs and urine output every 4 hours.
7. Monitor for any post-procedure complications, such as bleeding and signs of
perforation such as abdominal distention and pain.
8. Encourage patient to express his concerns, if any.
9. Resume patient’s oral food intake after the procedure, avoiding dark-colored
foods.
10. Continue to monitor his vital signs, urine output and bowel movements, paying
particular attention to blood in the stool.

PATIENT EDUCATION
1. Advise the patient to take iron pills. Also educate the patient that iron pills often make
your bowel movements dark or green. If he forgets to take an iron pill, do not take a
double dose of iron the next time he takes a pill.
2. Advise the patient to eat foods rich in vitamin C, such as citrus fruits or juice, peppers,
and broccoli. Some foods can make it harder for your body to absorb iron, such as
coffee, tea, milk, egg whites, fiber, and soy protein. These must be avoided to prevent
iron deficiency anemia.

FOLLOW-UP
1. Monitor for new or progression of existing symptoms that may indicate worsening
condition and monitor stool output and passage of flatus for worsening to complete
obstruction
2. Screen patient and family members ages 40 and above every 10 years (average risk) for
colon cancer using colonoscopy.
YANO, CASEY RAE T. Block 6
Department of Surgery
Facilitator: Dr. Navarro

Progress Notes
Hospital Day 5
A. Subjective:
The patient is no longer dyspneic. He had no trouble sleeping, had a good appetite and
ate fish and rice that morning. He consumed approximately 10 cups of water and was able to
urinate well without dysuria. He was able to pass solid stool once with no pain, however, the
patient noted it to be reddish. No other associated symptoms such as chest pain, fever, and
nausea were noted. Patient noted that he was still waiting for his biopsy results before
undergoing surgery, and that his physician suggested for him to get an angiogram to check the
blood vessels of his heart for any abnormalities. However, this was not required by his
physician.

B. Objective Findings:

General Survey: Patient was examined alert, awake, coherent, cooperative, and not in
respiratory distress.

Vital signs:
BP: 130/80, (right arm sitting) Temp: 35 ‘C C, (Right axilla)
HR: 59 bpm, (right radial, sitting) Height: 165cm (5’5”)
RR: 20 cpm Weight: 60.7 kg
O2Sat: 97% at room air BMI: 22.3 kg/m2 (normal)

Physical Examination:

Skin: Skin is dry, warm, and smooth to touch, with good skin turgor and mobility. No lesions are
seen. No rashes, petechiae, ecchymoses, discolorations or jaundice. No cyanosis or clubbing in
nails.

HEENT:
Head: atraumatic,symmetric, with black/brown hair evenly distributed throughout the head. No
flakes, no scales nor lumps seen on the scalp. No tenderness.
Eyes: Pterygium both eyes, L @ 9 o’clock R @ 9 o’clock. White sclera, well-aligned with no
deviations nor protrusions, eyebrows evenly distributed with no flakes, equal palpebral fissures,
pinkish palpebral conjunctivae, transparent sclerae, brown lens. (+) red reflex on both eyes with
pupils round, 2 mm in both eyes, equally reactive to light, direct and consensual, full range
extraocular muscle movements by Finger Following Test, good convergence, no visual field
defects by Confrontation test
Ears: no deformities, no tenderness, no discharges, tympanic membrane pearly gray and intact
bilaterally, able to hear whispered voice at 2 feet distance
Nose and Paranasal Sinuses: no deformities, no alar flaring, nasal septum midline, no
discharges, no tenderness over the paranasal sinuses, able to transilluminate
Mouth and Pharynx: pink and moist lips, buccal mucosa pink, no lesions, complete dentition,
tongue midline on protrusion, no lesions, uvula midline, no tonsillopharyngeal congestion
Neck: trachea midline, neck veins not engorged, cervical lymph nodes not palpable, thyroid
gland not palpable

Breast & Axilla: not assessed

CARDIOVASCULAR: Adynamic praecordium, JVP is at 2 cm from sternal angle. PMI at 5th ICS
and not displaced. S1 & S2 distinct. Regular cardiac rhythm, no murmurs and bruits.

ABDOMEN: Abdomen is symmetrical and flat, with normoactive bowel sounds at 10clicks/min.
Generally tympanitic with dullness over the liver. Liver span 4cm at MSL and 6cm at right MCL.
No palpable masses. No hepatomegaly no splenomegaly. No costovertebral angle tenderness.

Genitourinary: No inguinal adenopathy. Grossly female. No rashes or lesions.

Rectum and Anus: Not assessed

Musculoskeletal: Normal range of motion at upper and lower extremities and all joints. Spine
straight.

PVS: No edema and varicosities. Extremities are warm to touch and non-tender. Brachial,
radial, femoral, dorsalis pedis, and posterior tibial pulses are palpable, brisk, +2 and bilaterally
symmetrical. Ulnar and radial arteries are patent. CRT < 2 seconds.

Neurologic examination:

Mental status: Patient is awake, oriented to person, place, & time; cooperative, relaxed,
coherent. Recalls recent & remote memory correctly.

Cranial nerves:
I - able to identify scent coffee bilaterally
II - visual acuity 20/20 bilaterally
II. IV, VI - EOM intact, no nystagmus, intact pupillary light reflex (direct & consensual)
V - intact facial sensation bilaterally
VII - symmetric facial expressions
VIII - hearing intact bilaterally to whispered voice test
IX, X - able to swallow saliva, uvula & soft palate midline, well-modulated voice
XI - able to rotate head & shrug shoulders against resistance bilaterally
XII - tongue midline on protrusion
Sensory - intact light touch and stereognosis bilaterally
Cerebellar - able to perform finger to nose test
Motor - normal muscle tone; no atrophy or fasciculations; 5/5 muscle strength
 5/5 5/5

5/5 5/5

Pertinent Labs:
(January 29, 2023)

CT scan abdomen:

Laboratory Findings
Immunology (January 31, 2023)
NT proBNP
NT proBNP result: H 269.30 pg/ml <125
H 31.78 pmol/L <14.7

Clinical Microscopy (February 02, 2023)

URINALYSIS RESULT UNIT REFERRENCE
Macroscopic
Color Yellow
Appearance Clear
Chemistry
pH 6.0 5-8.5
Specific Gravity 1.005 1.005-1.030
Protein Trace
Glucose Negative Negative
Ketones Negative mg/dL Negative
Blood Negative Negative
Urobilinogen Normal umol/L Ehrlich units/dL
Nitrite Negative Negative
Leukocyte Esterase Negative Negative
Bilirubin Negative Negative
Microscopic
RBC 0-2 /uL 0-2
WBC 0-2 /uL 0-2
Epithelial Cells Rare
Mucus Threads Rare
Bacteria Rare
 Cast None seen

Upper Endoscopy (February 03, 2023)

● Post-Endoscopic Diagnosis:
1. Non Erosive antral gastritis
2. Esophagitis Gr. A (LA Classification)

o H.Pylori Test: Positive

o Esophagus: Mucosal breaks <5mm noted just above the z-line
o Stomach: Patchy mild hyperemia in the antrum
o Duodenum:
1st portion: Normal
2nd portion: Normal

Colonoscopy
● Post-Endoscopic Diagnosis:
1. Fungating mass at 50cm depth from the anal verge (R/I CA) - biopsied
2. Sessile polyp – ascending colon (proximal) – polypectomy done
3. Diverticulosis, ascending colon
4. Internal hemorrhoidal disease Gr I

o Anus/Rectum: Raw, abraded internal hemorrhoids at 11,1,5,7 o’clock

o Sigmoid: Normal
o Descending colon: 50 cm depth: Fungating mass – 5-10cm extent occupying
30% of wall circumference – biopsied
o Transverse colon: Normal
o Ascending colon: Diverticular openings noted; sessile polyp 3cm diameter –
polypectomy done (piecemeal)
o Cecum: Normal
o Depth/Anatomic Extent: Cecum

Immunology & Serology (February 03, 2023)

HBsAg (Qualitative) Non Reactive
CEA 4.13 ng/mL Nonsmoker: <=2.30
Smoker: <=4.10

Clinical Chemistry (February 03, 2023)

Test Result Unit Reference Range
TPAG
Total protein 6.3 g/dL 6.3-8.2
Albumin 3.7 g/dL 3.5-5.0
Globulin 2.6 L g/dL 2.8-3.2
A/G ratio 1.42 1.3-1.6

Complete Blood Count (February 03, 2023)

TEST RESULT REFERENCE

WBC 10.74 4.5-11.0

 Differential Count
- Seg. Neutrophils 72 (H) 45-60
- Lymphocytes 16 (L) 20-40
- Monocytes 10 2.0-9.0
- Eosinophils 2 0-6
- Basophils 0 0-2
Total 100
RBC 4.0 3.5-5.1
Hgb 9.1 g/dL (L) 12.0-15.0
Hct 29.4 % (L) 38.48
MCV 73.1 fL 70-90
MCH 22.6 pg (L) 23-31
MCHC 31.0 g/dL 30-35
RDW-CV 18.9 % (H) 11-16
Platelet count 467 (H) 150-450

Chest PA (February 04, 2023)

Impression:
Subsegmental Atelectasis, Left Lower Lobe
Atherosclerotic aorta
Thoracic spondylosis

CT of the Abdomen with Contrast

There is an ill-defined, heterogeneously enhancing, focal wall thickening in the distal
descending colon measuring approximately 1.3 cm in maximal thickness and approximately 4.0
cm in length causing mild luminal narrowing. Few small calcified and noncalcified, air-filled wall
outpouchings are noted in the ascending colon. Irregular wall thickening and enhancement
along the medial aspect of the 3rd and 4th portions of the duodenum are noted. Bowel
gas-pattern is non-obstructive. The rest of the visualized gastrointestinal tract is grossly
unremarkable. The appendix is normal in size.

The prostate gland is slightly enlarged measuring approximately 4.1 x 4.9 x 3.6 cm (36.8g).

Assessment

J.P., a 68-year old male, initially presented with exertional dyspnea that is suggestive of
anemia, which is further supported by his CBC findings of a low RBC, hemoglobin, hematocrit,
MCV, MCH, and MCHC. Because no obvious source of bleeding was present, a primary
impression of iron-deficiency anemia secondary to occult gastrointestinal bleeding was
considered. However, upon further evaluation with an upper endoscopy, colonoscopy, CT scan
with contrast of the abdomen, and determination of CEA levels, my assessment of this patient is
now of a suspected colorectal carcinoma. This is further supported by the findings of the
colonoscopy, which found a fungating mass on the descending colon 50 cm depth from the anal
verge, measuring 5-10 cm in size and occupying 30% of the wall circumference, and the
elevation in CEA which is a marker for colorectal cancer. A biopsy was done on the mass,
however biopsy results are still pending. Further surgical management can be planned upon
receiving the final biopsy results. Furthermore, an upper GI bleed can now also be ruled out due
to the negative findings of the upper endoscopy. In addition, patient’s dyspnea has been
resolved, and he has good appetite. He had no signs and symptoms of post-colonoscopy and
endoscopy complications such as abdominal distention, or chest or abdominal pain. He also
notes no changes in bowel movements, or pain and difficulty in passing stool. No problems in
voiding were noted.

Plan
1. Carvedilol (Carvid) 25mg tab OD after breakfast
2. Amlodipine + Losartan 50/5 mg tab OD after breakfast for his hypertension
3. Await for biopsy results

Patient Education
1. Educate patient on starting a healthy diet - a high intake of dietary fiber (from eating
fruits, vegetables, and cereals) and a low intake of fat and red meat and active lifestyle
2. Educate patient of reduction of alcohol drinking or cessation

Follow up
1. Screen patient and family members ages 40 and above every 10 years (average risk) for
colon cancer using colonoscopy.
Case Presentation
Department of
Surgery
Block 6
Apacible | Fuerzas | Jumamoy | Lim | Petalcorin | Yano

February 08, 2023

 General Data
● J.P. INFORMANT: Patient
RELIABILITY: 87%
● 68 - year old
● Male
● Married
● Filipino
● Roman Catholic
● Retired Mining Engineer
● Currently living in Lapu-Lapu City, Cebu
● Was admitted for the first time on February 2, 2023, 1:30 AM at
UCMed due to exertional dyspnea
 02
Chief Complaint
Exertional Dyspnea
 03
Past Medical
History
 Past Medical History
● Complete childhood immunizations from barangay health center
● History of measles and mumps in elementary school (uncomplicated)
● No history of chickenpox and rubella
● Diagnosed with hypertension in 2005
○ Losartan K + Amlodipine besilate (Amlife) 10mg OD
○ Usual BP: 110/70 mmHg
○ Highest recorded: 130/90 mmHg
● Non-diabetic and non-asthmatic
 Past Medical History
● Completely vaccinated against COVID-19
○ 2 doses (Sinovac) and 1 booster dose (Pfizer), unrecalled
● History of slipped disc in 2004
○ While playing basketball
○ Suggested to have surgery
○ Did not comply; opted for traditional medicines
○ Difficulty in mobilization and walked with a cane for 3 months
○ No rehabilitation done
 Past Medical History
● Hospitalized in 2006 due to blurring of vision
○ Medications were unrecalled
○ Discharged improved after 2 days with no complications
● Sought consult for flank pain in 2018
○ Diagnosed UTI secondary to urolithiasis
○ Enlarged prostate found incidentally
○ Medications (unrecalled) taken with poor compliance
○ Condition resolved without complications
 Past Medical History
● No history of surgical procedures nor psychiatric consultations
● Annual health screenings
○ Unrecalled laboratory tests ordered
○ All results were unremarkable
 04
Family History
 Family History
● Heredofamilial diseases:
○ Maternal: Diabetes mellitus
○ Paterna: Thyroid disorders (unspecified)
● Parents died of old age in their 70’s
○ Mother is a former barangay captain
○ Father is a former city councilor
● Birth rank 5/7
○ Eldest sibling died in a motor vehicular accident
○ One sibling is diabetic
● Has 3 children, aged 29-32
○ All healthy with no known diseases
 05
Personal &
Social History
 Personal and Social History
● Graduate of BS Mining Engineering
● Worked in Surigao City for 30 years as a mining engineer
○ Recently retired
○ Works occasionally as a consultant
● Lives with his wife and son in a concrete house
● Non-smoker and no history of illicit drug use
● Occasional alcoholic beverage drinker, but stopped at age of 60
● Usual diet: Fish, chicken, rice, vegetables prepared by wife
 Personal and Social History
● Regular bowel movements
● No problems in voiding
● Sleeps approx. 8 hours per day
● Exercise:
○ Hand grippers
○ Walking
○ Basketball (stopped due to old age)
● Claims to be sexually active with his wife
○ Total of 2 sexual partners
● No history of contraceptive use.
● No recent travel history
 06
History of
Present Illness
30 days PTA
● patient had a sudden onset of dyspnea upon walking for at least 3 meters on a flat
plane
● noted while the patient was walking around the house

5 days PTA
● dyspnea persisted, and was still noted to be aggravated by exertion and relieved by
rest
● Persistence of dyspnea prompted the patient to seek consult at a private clinic in
Surigao.
● Test results showed that the patient had anemia, with decreased RBC, hemoglobin
(7.1 g/dL), hematocrit, MCV, MCH, and MCHC, elevated basophils and platelets,
hyperkalemia (5.3 mmol/L), low HDL cholesterol, elevated FBS, elevated NT-proBNP,
and elevated PSA (5.56 ug/L).
● referred to UCMed due to the unavailability of laboratory procedures in Surigao
● No medications were taken
1 day PTA
● Exertional dyspnea persisted
● Patient sought consult at a private clinic in UCMed for further work-up on his
condition
● Patient was then advised to seek admission to further evaluation
● No medications were taken by the patient

On the day of admission

● patient’s dyspnea persisted, which was still aggravated by exertion and
relieved by rest
 07
Physical
Examination
Physical Examination
General Survey: patient was examined awake, coherent, not in pain, and
not in respiratory distress

BP: 130/100 (R arm, sitting) O2 Sat: 96%, Room Air

HR: 88 bpm Height: 165cm
RR: 20 cpm Weight: 60.7 kg
Temp: 35.6 (R, axillary) BMI: 22.3 (Normal)
 Physical Examination
Skin: fair, no jaundice, no cyanosis, smooth, warm to touch, good turgor and mobility
HEENT:
Head: Normocephalic ,black hair evenly distributed throughout the head, no flakes, no scales nor lumps seen on
the scalp. No tenderness.
Eyes: non-sunken eyeballs, white sclera, well-aligned with no deviations nor protrusions, eyebrows evenly
distributed with no flakes, equal palpebral fissures, pinkish palpebral conjunctivae, (+) red reflex on both eyes,
pupils round, 2 mm in both eyes, equally reactive to light. Pterygium both eyes, L @ 9 o’clock R @ 9 o’clock
Ears: no deformities, no tenderness, no discharges, tympanic membrane pearly gray and intact bilaterally,able to
hear whispered voice at 2 feet distance
Nose and Sinus: Nasal septum midline, no deformities, no alar flaring, no discharge,
nontender paranasal sinuses
Mouth and Throat: Lips and oral mucosa are moist, no lesions. Dentition good with
no dental caries. Tongue midline. No tonsillopharyngeal congestion
Neck: Supple, no cervical lymphadenopathies, trachea midline, neck veins not
engorged, no carotid bruits.
 Physical Examination
Cardiovascular: Adynamic precordium; 2 cm, brisk and forceful apical impulse palpable over 5th left intercostal space,
midclavicular line; JVP is at 2.5 cm from sternal angle. no thrills or heaves; cardiac area of dullness not enlarged, regular
rhythm, distinct S1 and S2, no murmur

Chest and Lungs: Thorax is symmetric with good expansion. Lungs resonant. No rales or crackles. Diaphragm descends 4
cm bilaterally.

Breast and Axilla: Breast is flat and symmetrical. Nipples are brown, symmetrical and without rashes, ulcerations nor
discharge. No palpable masses. Axilla is smooth. No palpable lymph nodes on both axillae.

Abdomen: Rounded, no visible vessels, no rashes, redness, scars, and lesions. Normoactive bowel sounds of 10 clicks
per minute. Soft abdomen, no palpable masses. No direct tenderness and rebound tenderness on all 4 quadrants. Dullness
on RUQ and RLQ upon percussion.

GUT: Not assessed

Rectum & Anus: Not assessed
Physical Examination
NEUROLOGIC EXAMINATION
Mental Status Exam: Patient is awake, conscious, active, and cooperative. He is oriented to person, place, and time. Recent
and remote memory are both intact. Speech is fluent and words are clear. Thought process, content, and insight are all intact.

Cranial Nerves:
I: able to identify smell of coffee grounds through both nostrils
II: pupil equal, round, reactive to both light and accommodation 20/200 visual acuity by jaegers chart
III, IV, VI: Extraocular muscles are intact
V: temporal and masseter strength intact, (+) corneal reflex
VII: no facial asymmetry noted, no nasolabial folds, no forehead wrinkling
VIII: able to hear whispered voice at 2ft
IX, X: (-) gag reflex
XI: no shoulder lag, could raise both shoulders against maximal resistance
XII: Tongue and uvula at the midline

Motor: Good muscle bulk and tone. No atrophy noted through comparison of both left
and right muscle groups. All muscle strength graded 5/5.

Cerebellar: Finger-to-nose test and rapid alternating movement are good

Sensory: Pinprick, light touch, and stereognosis are intact

 Salient Features
● Exertional dyspnea
● Low hemoglobin count
● Low MCV, Low MCH
● increased platelet count
● high NT proBNP
 08
Primary
Impression
 Iron-Deficiency Anemia
Secondary to Occult
Gastrointestinal Hemorrhage
 09
Differential
Diagnosis
 Anemia of Chronic Pulmonary Embolism Congestive Heart Failure
Disease/Cancer

Rule in: Rule In: Rule In:

(+) Age (+) Hypertensive (+) Hypertensive
(+) Weight loss (+) Exertional dyspnea (+) Exertional dyspnea
(+) Exertional dyspnea
(+) Microcytic Hypochromic anemia

Rule out: Rule Out: Rule Out:

(-) Family History of Cancer
(-) Fatigue
(-) history of surgery and trauma (-) aggravation by lying supine
(-) varicose veins (-) cyanosis
(-) drug abuse (-) signs of pulmonary edema (Rales)
(-) Warfarin use (-) Hepatomegaly, ascites
(-) cough (-) Peripheral edema
 10
Diagnostics &
Management
 DIAGNOSTIC PLAN
● Definitive
○ Bidirectional Endoscopy
● Supportive
○ Fecal Occult Blood Test
○ Chest X-ray
○ CBC
○ Blood typing
○ Prothrombin time
○ Serum creatinine
 THERAPEUTIC PLAN

● Definitive
○ Adequate volume resuscitation
○ Blood transfusion
○ Surgical management
 THERAPEUTIC PLAN
● Supportive
○ Inform the patient about his condition and the reason why further evaluation of his
anemia is important.
○ Inform the patient about the procedures needed to evaluate his symptomatic
anemia, such as a search for the source of bleeding. Inform him of the need of an
upper endoscopy to look upper GI bleeds, and a colonoscopy to look for sources of
lower GI bleeds, including its possible complications.
○ Ask and obtain a signed consent form for the procedures.
○ Place the patient on NPO 6-8 hours before the procedure.
○ Prepare the patient for colonoscopy with complete oral bowel preparations.
○ Establish an IV line for intravenous fluids. Start infusion of D5W 1L at a rate of 100
cc/h.
 THERAPEUTIC PLAN
● Supportive
○ Monitor patient’s vital signs and urine output every 4 hours.
○ Monitor for any post-procedure complications, such as bleeding and signs
of perforation such as abdominal distention and pain.
○ Encourage patient to express his concerns, if any.
○ Resume patient’s oral food intake after the procedure, avoiding
dark-colored foods.
○ Continue to monitor his vital signs, urine output and bowel movements,
paying particular attention to blood in the stool.
 11
Progress Notes
 Subjective findings
● No longer dyspneic
● No trouble sleeping
● Good appetite
● Good urination without dysuria
● Able to pass stools (noted to be reddist)
● No other associated symptoms such as chest pain,
fever, and nausea were noted
● Waiting for biopsy results
 Objective findings
General survey: The patient was examined awake, coherent, cooperative,
and not in respiratory distress.

Vital Signs:
BP: 130/80 mmHg (R arm, sitting)
HR: 59 bpm
RR: 20 cpm
Temp: 35C (L, axillary)
O2 sat: 97% at room air
Weight: 60.7 kg
Height: 5’5 ft
BMI: 22.3 kg/m2 (Normal)
 Physical Examination
Skin: fair, no jaundice, no cyanosis, smooth, warm to touch, good turgor and mobility
HEENT:
Head: Normocephalic ,black hair evenly distributed throughout the head, no flakes, no scales nor lumps
seen on the scalp. No tenderness.
Eyes: non-sunken eyeballs, white sclera, well-aligned with no deviations nor protrusions, eyebrows evenly
distributed with no flakes, equal palpebral fissures, pinkish palpebral conjunctivae, (+) red reflex on both
eyes, pupils round, 2 mm in both eyes, equally reactive to light. Pterygium both eyes, L @ 9 o’clock R @
9 o’clock
Ears: no deformities, no tenderness, no discharges, tympanic membrane pearly gray and intact
bilaterally,able to hear whispered voice at 2 feet distance
Nose and Sinus: Nasal septum midline, no deformities, no alar flaring, no discharge,
nontender paranasal sinuses
Mouth and Throat: Lips and oral mucosa are moist, no lesions. Dentition good with
no dental caries. Tongue midline. No tonsillopharyngeal congestion
Neck: Supple, no cervical lymphadenopathies, trachea midline, neck veins not
engorged, no carotid bruits.
 Neurologic Examination
NEUROLOGIC EXAMINATION
Mental Status Exam: Patient is awake, conscious, and cooperative. He is oriented to person, place, and time. Recent and remote
memory are both intact. Speech is fluent and words are clear. Thought process, content, and insight are all intact
Cranial Nerves:
I: able to identify smell of coffee grounds through both nostrils
II: pupil equal, round, reactive to both light and accommodation 20/200 visual acuity by jaegers chart
III, IV, VI: Extraocular muscles are intact
V: temporal and masseter strength intact, (+) corneal reflex
VII: no facial asymmetry noted, no nasolabial folds, no forehead wrinkling
VIII: able to hear whispered voice at 2ft
IX, X: not assessed
XI: no shoulder lag, could raise both shoulders against maximal resistance
XII: Tongue and uvula at the midline

Motor: Good muscle bulk and tone. No atrophy noted through comparison of both left
and right muscle groups. All muscle strength graded 5/5.

Cerebellar: Finger-to-nose test and rapid alternating movement are good

Sensory: Pinprick, light touch, and stereognosis are intact

Reflexes:
Chest and Lungs: No deformities, no intercostal retractions, equal tactile fremitus, equal
chest expansion, no crackles, no wheezes, nor rales
Breast and Axilla: Breast is flat and symmetrical. Nipples are brown, symmetrical and
without rashes, ulcerations nor discharge. No palpable masses. Axilla is smooth. Presence of
petechiae in the left axilla. No palpable lymph nodes on both axillae.
Cardiovascular: Adynamic precordium, JVP is at 2.5 cm from sternal angle. PMI at 5th ICS
and not displaced. S1 & S2 distinct. Regular cardiac rhythm, no murmurs and bruits.

Abdomen: Abdomen is protuberant, with normoactive bowel sounds at 26 clicks/min.

Dullness over the liver. Liver span 4cm at MSL and 6cm at right MCL. No direct and rebound
tenderness. No hepatomegaly no splenomegaly. No costovertebral angle tenderness.
Presence of guarding upon palpation.

GUT: No inguinal adenopathy. Grossly male. No rashes or lesions.

Rectum and Anus: Not assessed
Musculoskeletal: Normal range of motion at upper and lower extremities and all joints. Spine
straight.
PVS: No varicosities. Presence of edema on left foot. Left lower extremity is cool to touch and
tender. Both upper and right lower extremities are warm to touch and nontender. Brachial,
radial, and femoral pulses are palpable, brisk, +2 and bilaterally symmetrical. Absent dorsalis
pedis, and weak posterior tibial pulse. Ulnar and radial arteries are patent. CRT < 2 seconds.
 Laboratory Findings
Immunology (January 31, 2023)
NT proBNP
NT proBNP result: H 269.30 pg/ml <125
H 31.78 pmol/L <14.7
 Clinical Microscopy (February 02, 2023)

URINALYSIS RESULT UNIT REFERRENCE

Macroscopic
Color Yellow
Appearance Clear
Chemistry
pH 6.0 5-8.5
Specific Gravity 1.005 1.005-1.030
Protein Trace
Glucose Negative Negative
Ketones Negative mg/dL Negative
Blood Negative Negative
Urobilinogen Normal umol/L Ehrlich units/dL
Nitrite Negative Negative
Leukocyte Esterase Negative Negative
Bilirubin Negative Negative
Microscopic
RBC 0-2 /uL 0-2
WBC 0-2 /uL 0-2
Epithelial Cells Rare
Mucus Threads Rare
Bacteria Rare
Cast None seen
 Immunology & Serology (February 03, 2023)
HBsAg (Qualitative) Non Reactive
CEA 4.13 ng/mL Nonsmoker: <=2.30
Smoker: <=4.10
Upper Endoscopy (February 03, 2023)
● Post-Endoscopic Diagnosis:
1. Nonerosive antral gastritis
2. Esophagitis Gr. A (LA Classification)

o H.Pylori Test: Positive

o Esophagus: Mucosal breaks <5mm noted just above the z-line
o Stomach: Patchy mild hyperemia in the antrum
o Doudenum:
1st portion: Normal
2nd portion: Normal
Colonoscopy
● Post-Endoscopic Diagnosis:
1. Fungating mass at 50cm depth from the anal verge (R/I CA) - biopsied
2. Sessile polyp – ascending colon (proximal) – polypectomy done
3. Diverticulosis, ascending colon
4. Internal hemorrhoidal disease Gr I

o Anus/Rectum: Raw, abraded internal hemorrhoids at 11,1,5,7 o’clock

o Sigmoid: Normal
o Descending colon: 50 cm depth: Fungating mass – 5-10cm extent occupying 30% of wall circumference –
biopsied
o Transverse colon: Normal
o Ascending colon: Diverticular openings noted; sessile polyp 3cm diameter – polypectomy done (piecemeal)
o Cecum: Normal
o Depth/Anatomic Extent: Cecum
 Clinical Chemistry (February 03, 2023)
Test Result Unit Reference Range
TPAG
Total protein 6.3 g/dL 6.3-8.2
Albumin 3.7 g/dL 3.5-5.0
Globulin 2.6 L g/dL 2.8-3.2
A/G ratio 1.42 1.3-1.6

TEST RESULT REFERENCE

WBC 10.74 4.5-11.0

Complete Blood Count Differential Count
(February 03, 2023) - Seg. Neutrophils 72 (H) 45-60
- Lymphocytes 16 (L) 20-40
- Monocytes 10 2.0-9.0
- Eosinophils 2 0-6
- Basophils 0 0-2
Total 100
RBC 4.0 3.5-5.1
Hgb 9.1 g/dL (L) 12.0-15.0
Hct 29.4 % (L) 38.48
MCV 73.1 fL 70-90
MCH 22.6 pg (L) 23-31
MCHC 31.0 g/dL 30-35
RDW-CV 18.9 % (H) 11-16
Platelet count 467 (H) 150-450
 Chest PA (February 04, 2023)
Impression:
Subsegmental Atelectasis, Left Lower Lobe
Atherosclerotic aorta
Thoracic spondylosis

CT of the Abdomen with Contrast

There is an ill-defined, heterogeneously enhancing, focal wall thickening in the distal
descending colon measuring approximately 1.3 cm in maximal thickness and
approximately 4.0 cm in length causing mild luminal narrowing. Few small calcified
and noncalcified, air-filled wall outpouchings are noted in the ascending colon.
Irregular wall thickening and enhancement along the medial aspect of the 3rd and
4th portions of the duodenum are noted. Bowel gas-pattern is non-obstructive. The
rest of the visualized gastrointestinal tract is grossly unremarkable. The appendix is
normal in size.

The prostate gland is slightly enlarged measuring approximately 4.1 x 4.9 x 3.6 cm
(36.8g).
 Assessment
Diagnosis: Suspected Colorectal carcinoma

Further supported by the findings of the colonoscopy, which found a fungating

mass on the descending colon 50 cm depth from the anal verge, measuring
5-10 cm in size and occupying 30% of the wall circumference, and the
elevation in CEA which is a marker for colorectal cancer. A biopsy was done on
the mass, however biopsy results are still pending. Further surgical
management can be planned upon receiving the final biopsy results.
Furthermore, an upper GI bleed can now also be ruled out due to the negative
findings of the upper endoscopy.
Problem list

1. iron deficiency anemia secondary to occult bleeding

2. Sessile polyp ascending colon
3. tubulovillous adenoma with focal high grade dysplasia
4. BPH – benign prostatic hyperplasia
5. Essential HPN
6. Hyperkalemia
7. Left nephrolithiasis (non-obstructing)
8. type 2 dm (fbs 128 mg/dL)
9. ascending colon mass
10. non-erosive antral,Gastritis, esophagitis gr A
11. Internal hemorrhoids gr1
 Plan
Plan
1. Carvedilol (Carvid) 25mg tab OD after breakfast
2. Amlodipine + Losartan 50/5 mg tab OD after breakfast for his
hypertension
3. Await for biopsy results (to determine intervention plan on the
fungating mass because management of colon and rectal cancer is
stage–specific)
4. Use of Bowel Preparation in Elective Colon and Rectal Surgery
5. Include plan for the Abraded internal hemorrhoids
 Lifestyle & Nutrition
Patient Education
● A healthy body weight
● Active lifestyle
● A healthy diet - a high intake of dietary fiber (from eating fruits,
vegetables, and cereals) and a low intake of fat and red meat
● Reduction of alcohol drinking or cessation

The table below displays the guidelines for

colonoscopy surveillance after the primary
tumor resection

"Guidelines for colonoscopy surveillance after

screening and polypectomy: a consensus update by
the US Multi-Society Task Force on Colorectal
Cancer"
 12
Final Working
Diagnosis
 Suspected Colorectal Cancer
● 68M
● Alcoholic beverage drinker
● (+) hematochezia, anemia
● Diagnosed with Type II DM
● Colonoscopy: fungating mass at 50 cm depth from the anal verge
● Elevated CEA
● Whole CT of the Abdomen: ill-defined, heterogeneously enhancing, focal
wall thickening in the distal descending colon measuring approximately 1.3
cm in maximal thickness and approximately 4.0 cm in length causing mild
luminal narrowing. Few small calcified and noncalcified, air-filled wall
outpouchings are noted in the ascending colon.
 13
Case Discussion
RISK FACTORS
 PATHOGENESIS

01 LOH (Loss of heterozygosity) Pathway

02 RER (Replication error) Pathway

03 CpG Island Methylation Pathway

DIAGNOSTIC MANAGEMENT:
Colonoscopy
TNM STAGING
TNM STAGING
 SURGICAL TREATMENT
Illustration by Smart-Servier Medical Art

Total Resection of
Tumor
Thank you!