Return to Scenario ListShow Learning Points most relevant to Phase 1:

Rectal bleeding

Clinical Discipline(s)/Organ System(s)
Anatomical Pathology, Gastroenterology & Hepatology, General Practice, General Surgery, Medical Genetics, Digestive System, Palliative Medicine, Oncology
Progress Test Topic(s)
A 55 year old NZ European man presents to his GP as he has seen blood when he is passing a bowel motion. He is distressed as his father died of bowel cancer. You are the trainee intern attached to the clinic and are asked to see him before the doctor. You are reminded of your own family/whanau as a family member died of bowel cancer in their 50's.
Progress Test-Type Questions:   Question 1 | Question 2 | Question 3 | Question 4
Applied Science for Medicine 
   - Anatomy of the lower gastrointestinal tract and pelvis
   - Physiology of nutrition, digestion, fluid balance, haemostasis
   - Pathology of colorectal adenocarcinoma, Crohn's disease, ulcerative colitis, diverticulitis, haemorrhoids, anal fissures
   - Mechanisms by which gene mutations are involved in the initation and progression of cancer; acquired (somatic cell) and inherited mutations
   - Genetics and pathology of hereditary bowel cancer
Clinical and Communication Skills 
   - History from a patient with rectal bleeding
   - Take a family history and construct a pedigree
   - Explore patient concerns about the bleeding and acknowledge bleeding may be a frightening symptom
   - Perform examination of abdomen, including rectal examination
   - Recognise red flag symptoms of gastrointestinal tract tumours, ischaemic bowel
   - Interpret full blood count, electrolytes, creatinine, liver function tests, coagulation screen
   - Differential diagnosis of rectal bleeding
   - Indications for family screening
   - Indications for CT abdomen and pelvis, rigid sigmoidoscopy, flexible sigmoidoscopy, colonoscopy
   - Discuss sensitively the possible diagnoses and need for further investigations
   - Explain to the patient: rigid sigmoidoscopy, flexible sigmoidoscopy, colonoscopy
   - Management of haemorrhoids, anal fissure, diverticulitis
   - Maintain an ongoing relationship with the patient, whatever the outcome
   - Outline management of colorectal adenocarcinoma, Crohn's disease, ulcerative colitis
   - Prognosis for colorectal adenocarcinoma, inflammatory bowel disease
   - Role of surgeon, gastroenterologist, oncologist, palliative care
Personal and Professional Skills 
   - Learn to manage your own uncertainty while awaiting the results
   - Maintain appropriate professional boundaries
   - Demonstrate insight into how this scenario may impact on your own emotional reactions and well-being. Debrief and seek support if necessary (see resources below)
   - Ethical and social implications of genetic testing
Hauora Māori 
   - Culturally safe engagement with this patient, his whānau and communities
   - Disparities by ethnicity along the bowel cancer pathway from screening through to diagnosis and management
   - Appreciate unique familial mutations in Māori families as a risk factor for developing cancers such as gastric cancer
Population Health 
   - Risks and benefits of screening for colon cancer on a population basis
Conditions to be considered relating to this scenario
haemorrhoids, anal fissure, anticoagulant-induced, angiodysplasia, colorectal cancer, diverticular disease
Less common but 'important not to miss'
ischaemic bowel, mesenteric ischaemia, pseudomembranous colitis, rectal varices, hereditary nonpolyposis colorectal cancer, familial adenomatous polyposis
inflammatory bowel disease, radiation proctitis

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