1. Third Session
1.1. Step (9): Review of Learning Objectives
1.1.1. Giude lines
1.1.1.1. evaluate the patinet amd stage and there are many appreaches
1.1.1.1.1. resectab
1.1.2. Resectable
1.1.3. Metastatic
1.1.4. Chemotherapy
1.1.4.1. Adjuvant
1.1.4.1.1. to remove what is left
1.1.4.2. Neoadjuvant
1.1.4.2.1. Prior to surgery in oreder to shrink the size of tumoer
1.1.4.3. Types
1.1.4.4. Side effects
1.1.4.4.1. Different from one person to another
1.1.4.5. Drugs
1.1.4.5.1. 5-FU
1.1.4.5.2. Lucoverin
1.1.5. Biological agent
1.1.6. Staging
1.1.6.1. Stage 1
1.1.6.1.1. Only surgical resiction
1.1.6.2. Stage 2
1.1.6.2.1. Surgery
1.1.6.3. Stage 3
1.1.6.3.1. Surgery and chemo
1.1.6.4. Stage 4
1.1.6.4.1. Palliative
1.1.7. Preop
1.1.7.1. clean the bowel content
1.1.7.1.1. Bicolax
1.1.7.2. Decide about the tumore site
1.1.8. Surgery
1.1.8.1. right hemicolictomy
1.1.8.2. transever hemi
1.1.8.3. left hemicolectmy
1.1.8.4. total colectomy
1.1.9. Screening
1.1.9.1. preevois cancer or polyp - family history - IBD - radiation
1.1.9.2. Colonescopy
1.1.9.3. sTOOL
1.1.9.3.1. Heme occult
1.1.9.3.2. Immune chemistery
1.1.9.4. Imaging
1.1.9.4.1. Enema
1.1.9.5. Recomended for every patient above 50
1.1.9.6. relative with colon cancer
1.1.9.6.1. 10 years erlier
1.1.9.6.2. or at 40 years
1.1.9.7. Rigid sigimodosopy - or flixble
1.1.10. Follow up
1.1.10.1. colonoscpy within 6 monthes
1.1.11. Survallance
1.1.11.1. follow up for 5 years
1.1.11.1.1. history and exame
1.1.11.1.2. CEA
1.1.11.1.3. anoual CT sace for first 3 years
1.1.11.1.4. pelvic anually for 5 - 6 years
1.1.11.1.5. rectosemgid for 5 -6 years
1.1.12. urgent operation - same was done for mother - examinatio under anstesia and colonscopy - there is tumer wafound - polyps were found
1.1.13. 10 days follower - admited because of pain and disrtention - obstruction - labroscopy no evidenca of maligangny in th evacity or liver - given 5 FU - some side efects - disk end block- 4 weeks later given another cycle
1.1.14. follow up
1.1.14.1. 1 year later >> better but dysparunia
1.1.14.2. adino APC stage 3 substage c 1 - both polyp were tubulovillis
1.2. Step (10): Management
1.3. Step (11): Feedback & Resources
1.3.1. Medscap
1.3.2. Current
1.3.3. uptodate
1.3.4. lectures
2. Second Session
2.1. Step (6): Review of Learning Objectives
2.1.1. Normal habits of bowel movement
2.1.1.1. Asborbtion of water soccurs in the colon and as this happens fecal material become more solid - strech in the sigmoid adn rectum producing a reflex -- fecal matarial will go up back again to the ascinding if you do not go to the toilt within couple of mintues - and then there will be more absorbtioion of water and let it more diffecutl
2.1.1.2. 2 - 3 times a day
2.1.1.2.1. Constipation
2.1.1.2.2. Dia
2.1.1.3. nORMAL CHARACTERSITCS
2.1.1.3.1. Soft
2.1.1.3.2. Brown in color
2.1.2. How to approach a patient with colorectal bleeding and a change in bowel habits
2.1.2.1. UGIB
2.1.2.1.1. melena
2.1.2.2. LGIB
2.1.2.2.1. hematochezia
2.1.2.3. Rectoragea
2.1.2.3.1. with out defecation
2.1.2.4. amount of bleeding
2.1.2.5. Age
2.1.2.5.1. More than 50 years you start to suspect malignancy
2.1.2.6. Chracter of bleeding
2.1.2.6.1. Time
2.1.2.6.2. Color
2.1.2.6.3. Pain
2.1.2.6.4. Associated symptoms
2.1.2.7. Diff
2.1.2.7.1. Hemorroid
2.1.2.7.2. Fissures
2.1.2.7.3. Rectal ulcers
2.1.3. Colorectal cancer
2.1.3.1. Epidemiology
2.1.3.1.1. 6 5 life time risk
2.1.3.2. Clinical features
2.1.3.2.1. Right side
2.1.3.2.2. Left side
2.1.3.2.3. Metastatic
2.1.3.3. Risk factors
2.1.3.3.1. Age
2.1.3.3.2. Family
2.1.3.3.3. IBD
2.1.3.3.4. Diet
2.1.3.3.5. Smoking
2.1.3.3.6. Familial
2.1.3.4. Pathogenesis
2.1.3.4.1. Most casis start with polyps
2.1.3.4.2. Most common type is adinocarcinoma
2.1.3.4.3. Genes implicated
2.1.3.4.4. If the cells were to generat faster such as in the case of IBD make it mre susptible to cancer
2.1.3.5. Screening
2.1.3.5.1. Colonoscopy
2.1.3.5.2. occult blood
2.1.3.6. How to diffrentiat between rectal and colon cancer
2.1.3.6.1. Surgery
2.1.3.6.2. Symptoms
2.1.3.6.3. Sigmoidoscopy
2.1.3.6.4. CT
2.1.3.7. Staging
2.1.3.7.1. TMN is the most accurate way
2.2. Step (7): Gathering Information & Inquiry Plan
2.2.1. History
2.2.1.1. constipation
2.2.1.2. Present history
2.2.1.2.1. rectal bleeding 6 weeks ago
2.2.1.2.2. Bright red with muscus
2.2.1.2.3. No anal pain
2.2.1.2.4. Abdominal pain and tenderness
2.2.1.2.5. No change in appetite, fever
2.2.1.2.6. Has to got to the toilet many times
2.2.1.2.7. Herbal tea was prescribed
2.2.1.2.8. OCT
2.2.1.3. Personal
2.2.1.3.1. pARENTS
2.2.1.3.2. Secretory
2.2.1.3.3. Smoking
2.2.1.4. Past medical
2.2.1.4.1. 2 years ago had cholesystoctomy
2.2.1.4.2. C- section
2.2.1.5. Family
2.2.1.5.1. Maternal mother treated for abdominal malignancy
2.2.1.5.2. Mother at age 65 diagnosed with colon cancer
2.2.1.5.3. Sister with breast cancer
2.2.2. Physical Examination
2.2.2.1. Thin and looks pale
2.2.2.2. 130/80
2.2.2.3. 90 beats regular
2.2.2.4. 37
2.2.2.5. 18
2.2.2.6. 162 - 60
2.2.2.7. Rectal examination is fine only hard mass at the tip of the finger
2.2.2.8. Dark blood seen on gloves
2.2.2.9. Lungs
2.2.2.9.1. normal
2.2.2.10. Abdominal examination
2.2.2.10.1. Scars cosis with past history
2.2.2.10.2. Fulness and mild tendernss in the flanck
2.2.2.11. CVE
2.2.2.11.1. normal
2.2.2.12. Neurological
2.2.2.12.1. normal
2.2.3. Investigation
2.2.3.1. biopsy shows ulcerative lesions, infiltration and poorly differentiating cells
2.2.3.2. Colonoscopy report
2.2.3.2.1. Midozolam and pethidin
2.2.3.2.2. Large lesion ocupying 75 percent of the anterior rectal wall
2.2.3.2.3. 1 anterior ulcerative lesion in the aterior rectal wall
2.3. Step (8): Diagnostic Decision
2.3.1. Mechanism
2.3.2. Presentation
2.3.2.1. 38 years old females presented with rectal bleeding (fresh blood), pale on examination, tender abdomen, palpable mass over the tip of the finger
2.3.3. Supporting Data
2.3.3.1. Bleeding, pale, tneder, ulcertative lesions in biopsy, mutible polyps
2.3.4. Objectives
2.3.4.1. Management of colocrectal cancer, screening
3. First Session
3.1. Step (1): Identifying Difficult Words & Cues
3.1.1. Difficult Words
3.1.1.1. "clock work"
3.1.1.1.1. very regular
3.1.2. Cues
3.1.2.1. female
3.1.2.2. 38 years old
3.1.2.3. rectal bleeding
3.1.2.4. mucus in stool
3.1.2.5. change in bowel habits
3.1.2.6. constipation (straining)
3.1.2.7. several visits to the toilet to be satisfied
3.1.2.8. concerned about operation
3.2. Step (2): Problem Formulation
3.2.1. 38 years old female presented with rectal bleeding, constipation and a change in bowel habits.
3.3. Step (3): Hypotheses Generation
3.3.1. rectal bleeding is seroius
3.3.1.1. Infectious
3.3.2. Fistula
3.3.3. Neoplasm
3.3.3.1. Obstructing the myentric plexus leading to cinstipation
3.3.3.2. Right side cancer presnts with chronic anemia
3.3.3.3. Left side presents with constipation
3.3.4. Vascular insult
3.3.4.1. By infection
3.3.4.2. Increased pressure
3.3.5. Hemorrhoids
3.3.6. Bleeding
3.3.6.1. UGIB
3.3.6.1.1. distal to the ligament of Teritz
3.3.6.2. LGIB
3.3.6.2.1. Hematochezia
3.3.7. Inflammatory bowel disease
3.3.8. Irritable bowel syndrome
3.4. Step (4): Hypotheses Organization
3.4.1. Infectious
3.4.2. Neoplasm
3.4.3. Inflammatory
3.4.4. Neurological
3.5. Step (5): Learning Objectives
3.5.1. 1- To describe the normal habits of bowel movement
3.5.2. 2- How to approach a patient with rectal bleeding and change in bowel habits
3.5.2.1. Differential, history, physical examination and invistigation
3.5.3. 3- To identify colorectal cancer (pathogenesis, risk factors, clinical features)