1. Step 8
1.1. Diagnostic decision
1.1.1. Rectal adenocarcinoma
1.2. Mechanism
1.2.1. multi factorial
1.2.1.1. family hx
1.2.1.2. enviromental factors
1.3. Presentation
1.3.1. change in bowel habit
1.3.2. constipation
1.3.3. rectal bleeding
1.3.4. abdominal tenderness
1.4. Supporting data
1.4.1. hx and PE
1.4.2. colonscopy and pathology report
1.5. 10 minutes
2. Step 7
2.1. Inquiry plan and info gathering
2.1.1. History of presenting complaint
2.1.1.1. 6 weeks hx of change in bowel habit
2.1.1.2. diagnosed with hemorrhoid
2.1.1.3. over the past 10 days, developed lower abdominal cramps and rectal bleeding, abdominal floating
2.1.1.3.1. sometimes the abdomin becomes tender
2.1.1.4. noticed blood stained mucous in the stool surfacew
2.1.1.5. 6 weeks ago noticed the blood stained mucous
2.1.1.6. strains to pass the stool
2.1.1.7. recently concerened with incomplete emptying
2.1.1.8. goes to the toilite several time in the morning to pass the stool
2.1.1.9. no change in weight or appetite , no anal pain
2.1.2. Previous medical / surgical history
2.1.2.1. 2 years ago had uncomplicated cholycystomy
2.1.2.2. 1 c-seccion
2.1.3. Drug history / allergy
2.1.4. Family history
2.1.4.1. maternal grandmother treated for abdominal malignancy
2.1.4.2. mother had bowel cancer, at age of 60
2.1.4.3. sister had breast cancer operation at age 40, live in italy
2.1.5. Social / occupational history
2.1.5.1. 5 ciggarate/day - for 5 years
2.1.5.2. 2 glasses of wine with evening
2.1.5.3. migated from italy to australia
2.1.5.4. avoids fatty food
2.1.5.5. goes regularu to gym
2.1.5.6. part time secretaroy after dilevering
2.1.5.7. takes OCP
2.1.6. Systemic review
2.1.7. Physical examination
2.1.7.1. vitals
2.1.7.1.1. BP 130/80
2.1.7.1.2. HR 90
2.1.7.1.3. temp 37.2
2.1.7.1.4. RR 18
2.1.7.1.5. hieght 162
2.1.7.1.6. weight 60
2.1.7.2. inspection
2.1.7.2.1. thin lady
2.1.7.2.2. looks anxious and pale
2.1.7.3. abdominal
2.1.7.3.1. scar consisted with past surgery
2.1.7.3.2. mild tenderness in right flank
2.1.7.3.3. lever and spleen not palable
2.1.7.3.4. auscultation showed occaisional perstaltic movement
2.1.7.4. chest
2.1.7.4.1. Normal
2.1.7.5. CV
2.1.7.5.1. JVP not raised
2.1.7.6. perinioum
2.1.7.6.1. no obvious abnormality
2.1.7.6.2. right mass felt in the tip of finger
2.1.7.6.3. dark blood seen after gloves withdrwal
2.1.8. tests results
2.1.8.1. sigmoid colonscopy
2.1.8.1.1. ulcerated mass lesion 7 cm
2.1.8.1.2. occypying 70% of the cercumfrntial of anterior rectal wall
2.1.8.1.3. 2 polyps with 1 cm diameter each
2.1.8.2. pathology report
2.1.8.2.1. ulcerative lesion adenocarcinoma of the large bowel
2.1.8.2.2. infiltration and well differentiation
2.1.8.3. trans rectal US
2.1.8.3.1. large ulcerated tumour invading all the anterior wall layers
2.2. 50 minutes
3. Step 6
3.1. Review session 1
3.2. Report new knowledge
3.2.1. colo-rectal neoplasm
3.2.1.1. pathophysiology
3.2.1.2. risk factors
3.2.1.3. types
3.2.1.4. staging
3.2.1.5. presentation
3.2.1.6. diagnosis
3.3. 30 minutes
3.3.1. The scribe does not have to write in this step!