SGD CORRELATION: RBR SUGGESTIONS MARCH 28, 2023 RECOMMENDED RESOURCES: 1. Robbins Pathologic Basis of Disease Text Book – Atlas and Textbook versions used for pathophysiology 2. Henry Clinical Diagnosis and Management and Laboratory Methods – For Laboratory Analysis and Correlation 3. Harrisons Principle if Internal Medicine – Clinical Practice Guidelines 4. Autopsy Pathology: A Manual and Atlas – For Organ Measurements 5. WHO Guidelines and CDC.gov – If applicable on the cases like parasites and microorganisms SUGGESTED THINGS NEED TO KNOW IF AN SGD IS DONE. 1. Know first the grading system. – This usually changes how the preceptor grade you individually or by as a group. Pay attention with the specific subsets and points from there you will prepare each of the parameters. 2. Take the SGD as your first encountered patient make it realistic. – As if this is your patient and diagnostic test labs, biopsies and imaging studies are being sent to you and you are trying to diagnose and treat the patient. 3. Know the CASE – Read the entire case paragraph by paragraph, and ENCIRCLE that makes you feel important clues and cues or select the best SALIENT FEATURES from the case that will guide your impression and create your differential diagnosis. Formulating Differential Diagnosis: a. Via System/Organ Approach – What organ/system are most likely affected in the case? b. Physiologic Approach – Example: Oxygen saturation is reduced, RBC on the sample is >100,000 cells, etc. (If given in the start of the history) c. Symptomatic Based Approach – Headache, Pain, Loss of Consciousness d. Clinical History about the patient – The patient uses prohibited drugs via parenteral injection and promiscuous behavior. e. Past Medical, Secondary Information, and Family History – The patient’s father died of colorectal adenocarcinoma. f. Age and Sex - This can used to delineate cases that are only common based on sex or age groups. Example: Prostate cancers is seen only MALES while Retinoblastoma is commonly seen in CHILDREN. From here stratify the salient features and make sure you combined all these approaches then select the possible differentials: At least make 3 possible differentials or at most 5. NB: But be guided sometimes in real life situation the patient may have one or two or more problem lists that can be related one another or can stand alone disease, meaning unrelated with one another.

Example: UNRELATED: Patient is having Prostate Cancer and Obstructive UTI is present. The patient also has TB of the Lungs and Hypertension. RELATED: Patient is HIV positive and not on HAART. VL = is 8million and CD4 = 60. She is having pneumonia due pneumocystis jiroveci, now develops severe anemia, and impending kidney failure. A. Infectious case differential B. Neoplastic case differential C. Structural defect/congenital differential D. Traumatic/Surgical case differential E. Medical case differential based on system (Stroke/MI/Etc.) From these examples you can now make suggestive investigations like doing laboratory test, histopathology, imaging with contrast, other tests that can support your differentials. 4. AVOID FISHING TO THE DIAGNOSIS – the diagnostic test/s are only done if you already formulated a valid correct patients’ history, list of salient features already stratified and differential diagnosis there already. CORRECT: Patient visited lake and had swimming. (+) Fever (+) Blurring of vision after 3 days (+) Toxic looking (+) Seizure

Differentials: 1. Acute case probably infectious bacteria/viral/parasitic. 2. Stroke 3. Dehydration 4. Structural/Tumor 5. DKA

Do CT-MRI Imaging mass/lesions in the brain.

=

To

see

Do CBC = Check if WBC is elevated, RBC Do CSF Analysis = See if Bacterial, Viral, Parasitic Do ABG = Status of O2 and pH in the body Do FBS = Check the Sugar, energy Do Electrolytes = Acidosis may affect the electrolytes may eventually affect conduction system of heart.

INCORRECT FIRST DO THE Differentials: FOLLOWING: Utilizing 1. Clueless will just rely on the tests even without the test outcomes. reason.

Chief complaint: Patient visit the you with chief complaint of vomiting.

Do CT-Scan of Abdomen Biopsy of the Stomach Do urinalysis Do ECG Do CBC ---------------------------------------------------------------------------------------------------------------SGD PROPER:

Salient Features 26-Year-Old Male

Differential Diagnosis Lifestyle Check – African living on Globalized Environment Sexual Orientation – Straight/Gay of Inherited Cancer

Father Died Colorectal Cancer 3 Months History of Progressive Abdominal Swelling (+) Shifting Dullness

Liver as Primary Disease – Oncotic Pressure Defects Cardiovascular Pressure Effects – Hydrostatic Pressure Defects Infection associated ascites. Malignancy in the GIT including the Peritoneal Cavity Structural Obstructions Malaise, Fever, Drench B-Symptoms associated with Lymphoma Night Sweats Infection Associated with Tuberculosis Other Infections Prohibited use of drugs Liver Damage to Drugs

Infection risk to blood borne transmissible diseases Progressive Weight Cancer Loss Malnutrition Chronic Inflammation Associated Nodulated Prostate Prostate Neoplasm Structural Defect Differential Diagnosis: Based on the Clinical History and Physical Examination DIFFERENTIALS SUPPORTING HISTORY DIAGNOSTIC TEST TO OR WORKING CONFIRM OR RULE OUT DIAGNOSIS HIV/AIDS Related Drug Abuse (Injectable?), Loss HIV Screening Test Complex in Weight ELISA Decompensated Drug Abuse (Injectable?), Imaging – CT Liver Disease Possible Infection to Hepatitis B Peritoneal Analysis – And Other Liver Transudative Involvement Biopsy of Liver SGPT and SGOT Abdominal TB Loss in Weight, B-Symptoms, Imaging – CT Location Epidemic Peritoneal Analysis – Exudative Biopsy of Liver GENEXPERT Add: Chest PA and Sputum AFB – R/O PTB Tumors of Lymphoid Lymphoma (Common also in Biopsy of Lesion = CD45 Origin the age group and sex), B- Imaging – CT Symptoms Bone Marrow Biopsy Peritoneal Family History, Obstructive Imaging – CT Carcinomatosis and Signs, Loss in Weight Peritoneal Analysis – Primary GIT Cancer Exudative Colonoscopy with Biopsy Barium with Triple CT Abdomen Prostate Neoplasm PE – Nodulation on Prostate via PSA Rectal Examination Imaging - CT

Primary Diagnosis: AFTER CONFIRMATION DIAGNOSTIC WORK-UP and SURGICAL INTERVENTION 1. Mucinous Adenocarcinoma, Sigmoid Colon 2. TNM = (pT4NXM1c) STAGE IVC T4 = Transmural Involvement and invasion of the adjacent organs NX = No lymph nodes were examined. M1c = Metastasis to the peritoneum with (Intestine, Stomach, Diaphragm involvements) or without other organ involvement.

3. Modified Dukes = D 4. Tumor extends Diaphragm (Muscle Tissue), Other intestinal tissues (ileum, jejunum, and stomach) 5. Others: Adenomatous Polyp (2.0-3.0 cm) with Necrosis CAUSE OF DEATH: CRITICAL the Tell-Tale Signs before the ONSET OF DEATH

Premorbid: 1. On and Off Fever Episodes, Shortness of Breath, Decreased Bowel Movements = 1 week of duration = Bacteremia Development 2. Frequent Abdominocentesis = Wound Infection (Surgical Drains) 3. Multiple Medical Interventional Puncture Sites (Dorsum of Hands and Abdomen) = Wound Infection 4. Post-Operative Abdominal Surgery Debulking Procedure = Peritonitis 5. Hospital set-up = >3 days Hospital stay (Nosocomial) Immediate Cause of Death: Complication associated with SIRS/Sepsis 1. Arrhythmia Antecedent Cause of Death: Polymicrobial Infections (Hospital Acquired) due to Skin Entry/Contamination (Device Related Infections), Intestinal Microbial Development (Ileus) and Hematogenous Spread Underlying Cause of Death: Colorectal Adenocarcinoma, Transmural Pathologic Involvement (Hemorrhages and Tumor Invasion), Bowel Ileus RISK FACTORS FOR ADENOCARCINOMA Robins: 814 Chapter 17: Epidemiology Section 1. Colorectal Adenocarcinoma is 10% Cancer Deaths in the World 2. Rates are lower in Africa vs. in United States (10-15%) all cases. 3. Incidence peak 60-70 years but 20% cases (age 50). 4.