Case Study Dan Browns Tutorial

29/04/13

After reading this case study, write down your hypothesis. Highlight your red flags and justify all your statements. For each of your hypothesis you will have to say what in the case study lead you to come up with it and what futher questioning to the patient will you be thinking of?

Case Study Dan Browns Tutorial

29/04/13

Hypothesis Colorectal cancer

Why Bright red Blood in the stool Age 50-75 higher risk Abdominal pain Male at higher risk

Prostate cancer

TURP (Transurethral Resection of the prostate) urological operation to treat BPH (Benign Prostatic Hyperplasia) Hxx of BPH is a predisposing factor for developing prostate cancer. Nocturia Age (Over 50 yoa) Abdominal pain

Further questioning Blood in the stool: Bright red blood in the toilet is more worrying than blood only visible on toilet tissue (Haemorrhoid). Any Hxx of: Organic pathology of the rectum Inflammatory Bowel Disease Poor diet: Low in fibre High in red meat, processed food and fat High intake of alcohol Poor life style: Lack of physical exercise Smoking Any family history of Colorectal cancer Any specific test recently done: FOBT (Fecal Occult Blood Test) Colonoscopy Sigmoidoscopy Other signs to look for: Constipation Anaemia Fever, nausea, lost of appetite Unexplained weight lost After a TURP intervention, PSA levels should be monitored. Urination: Problem starting and stopping Dribbling Pain Blood Erectile dysfunction Specific test: Physical examination PSA (level) Biopsy Advance prostate cancer can spread to bones, lymph nodes and brain. Look for Cauda Equina sings and neurological claudication

Prostate cancer metastasis to lumbar spine

Same as above plus LPB Prostate cancer can be silent (no symptoms). LBP with Lower ext. radiation bilaterally

Case Study Dan Browns Tutorial

29/04/13

Neurogenic claudication caused by Lumbar spinal stenosis (Due to degeneration, disc or tumor)

Bilateral leg pain Age (Degeneration of vertebral bone, osteophytes) Pain eased by pushing wheelchair

Vascular claudication

Hxx of high blood pressure, possibly uncontrolled risk of arthrosclerosis

Could be cause by AAA (common 65-75) abdominal pain Lower ext. bilateral symptoms

Type of pain in the Lower ext. (discomfort, weakness) Aggravated by: Walking Prolonged standing Relived by: Flexion from the waist Change is position Not just rest (like vascular claudication) Climbing step Cycling How far can he walk before the symptoms appear Type of pain (cramping, sense of fatigue, numbness ache) Aggravated by: Walking Exercise Relived by: Short period of rest Change in position Standing from sited position Risk factors: Smoking Poor diet and poor life style Other signs to look for: Cyanosis Decrease temperature Decrease pulse Less hair and shiny skin

Other to concider: Spondylolisthesis Double crush Triple crush Due to Hxx of parachute jump and manual work

More info: Infection in the late 30s was: Osteomyelitis of the tibia

Case Study Dan Browns Tutorial

29/04/13

Which caused Common Peroneal nerve (L4-S3) damage resulting in floppy foot.

Things you might want to look at: Blood in the stools (bright red, dark) Urinary test Possible causes of blood in stool (Diverticular disease, Anal fissure, Colitis, Angiodysplasia, Peptic ulcers, Polyps, Esophageal problems) PSA level: Normal and abnormal levels (age related) Early prostate cancer can be asymptomatic and when symptoms occur can be very similar to BPH. Common places for prostate cancer metastasis with associated signs and symptoms. Mechanism of metastasis

Examination you might want to perform: AAA: Abdominal exam (palpable pulse) Vascular claudication: Radial femoral delay Spondies: Palpable step Tuning fork Neurological claudication: Neurological test