GROUP 3

14-0046-228
13-0052-673
14-0048-697
14-0011-853

BAYOG, Charles Edward N.

BUHAY, Charles Vincent B.
CABRAL, Ma. Denise M.
CASTRO, Karl Angelo Q.

August 5, 2016
CPC/STP
Small Group Discussion

SUMMARY CASE PROTOCOL

SS, a 52-year-old female, complaints of weakness and fatigue, although she continued to work.
She attributed these changes to menopause; her menstrual periods have been irregular but occasionally
heavy. She experienced recent weight loss of 20 lbs over the past 6 months not attributable to diet or
exercise.
LABORATORY FINDINGS
- Initial laboratory workup shows
WBC: 5200 cells/mm3
Hemoglobin (Hgb): 7.5 g/dL
Hematocrit (Hct): 26%;
Red blood cell count (RBC): 3.5 x
106/L;
Platelet count: 650 000/L;
Mean Corpuscular Hemoglobin: 24.8
pg/cell;
Mean Corpuscular Hemoglobin
Concentration: 33.4 g/dL
Mean Corpuscular Volume (MCV):
55 m3

Reticulocyte count: 1.5%

Serum chemistries were:

Creatinine:1.1 mg/dL
Bilirubin (total): 0.9 mol/dL
Blood urea nitrogen: 15 mg/dL
Glucose: 124 mg/dL
Sodium: 134 mEq/L
Potassium: 4 mE q/L
Magnesium: 1.8 mEq/L
Calcium: 9.2 mg/dL

MEDICAL HISTORY
The patient reported chronic constipation and hemorrhoids, mild dyspnea on exertion, and
chronic arthritis in her knees and hands. She has been monitored for hypertension with current
control using diuretics. Her last mammogram 8 months ago was normal; the patient has had no
screening colonoscopy or sigmoidoscopy. Current medications include furosemide 100 mg orally
and ibuprofen 400 mg orally as needed. She took oral contraceptives for 10 years, but is
currently not receiving hormonal therapy.
FAMILY HISTORY
Her mother, aged 83 years, has type 2 diabetes (treated for 35 years) and her father died at age 60
of acute my ocardial infarction. One brother is alive at age 61 with hypertension.
SOCIAL HISTORY
SS owns and manages an interior design firm. She is divorced with 2 grown children and lives
alone. She has never smoked and rarely drinks alcohol. She is an avid tennis player.
PHYSICAL EXAMINATION
Appeared as a pale, thin woman in no acute distress. She was 56 tall and weighed 128 lbs. Vital
signs were as follows: blood pressure, 132/86 mm Hg; pulse, 86.
SALIENT FEATURES
Complaints of weakness and fatigue.
Irregular and heavy menstrual bleeding.
Weight loss of 20 lbs over the past 6 months not attributable to diet or exercise
Laboratory findings showed low levels of hemoglobin, hematocrit, red blood cell (RBC) count,
mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration and mean
corpuscular volume.
Laboratory findings also showed elevated levels of platelet count and reticulocyte count.
The patient reported chronic constipation and hemorrhoids.

With the given history and laboratory finding we can possibly consider cancer in this
case. The patient exhibited some of the warning signs for cancer based on the American Cancer Society
recommendations. These signs were:
Unusual bleeding or discharge from any opening in the body, example, blood in the urine,
stool, frequent or heavy menstruation.
A lump or swelling that has progressively enlarged which may or may not be associated
with pain.
Change in bowel or bladder habits consistently for duration of 2-3 months.
Unexplained tiredness and/or weight loss of 10% or more within a period of 3-6 months.
- DIFFERENTIAL DIAGNOSIS
Severe generalized muscle wasting is also seen as part of a number of degenerative
neurological and muscle diseases and in cardiac failure (cardiac cachexia) ruled out because of normal
cardiac exam and neurological abnormality was not manifested (neurological exam was not performed).

Thalassemia is a rare group of genetic blood disorders effecting red blood cells and
leading to anemia, ruled out bec there is no family history of this condition.
Tuberculosis usually infects the lungs that can cause dyspnea, weight loss and fatigue as
manifested by the patient, ruled out bec negative to cough with blood, chest pain, fever and chills.
Rectal cancer appears in the rectum and causes bloody stool and constipation.
Chronic kidney disease is a condition of the kidneys that can cause high blood pressure,
fatigue, and weakness.
Crohn's disease is a digestive condition that can cause nutritional problems,ruled out bec
there is no swelling, cramping anddiarrhea.
Chronic arthritis is an autoimmune disease that causes pain, swelling, and joint damage
manifested in the history.
Myelodysplastic syndromes are diseases that affect the bone marrow and blood, causing
anemia and tiredness as manifested. (Further evaluation or test needed)
Chronic fatigue syndrome (CFIDS) is a condition that causes extreme tiredness and
weakness, ruled out bec this type of weakness doesn't get better with rest which is not manifested.
People with congestive heart failure can have shortness of breath and fatigue but ruled
out by absence of irregular heartbeat and normal cardiac exams.
Celiac disease can also cause weight loss, ruled out by absence of intestinal reaction to
gluten, diarrhea, and bloating.
Hyperthyroidism causes weight loss and tiredness, ruled out by absence of sensitivity to
heat, insomnia, and lab test to confirm thyroid abnormalities.
Type 2 Diabetes can manifest tiredness or weakness; urination more than normal and
blurry vision was not manifested.
Vitamin B12 deficiency symptoms include fatigue, pale skin, and weakness;ruled out by
blood test absence of abnormality in morphology of cells.
Iron deficiency Anemia , a lack of red blood cells,can cause fatigue, pale skin, weakness,
pale conjunctiva, low Hemoglobin, hct, RBC ct and other clinical findings but ruled out by absence of
dizziness, headache and or any history of anemia, brittle nails, and irritability.
-

Colon cancer is often asymptomatic, but it can cause constipation, bowel obstruction and,
bloody stool. In addition, more advanced cases, clinically presents with iron-deficiency anemia, rectal
bleeding, abdominal pain, change in bowel habits, and intestinal obstruction or perforation. Right-sided
lesions are more likely to bleed and cause diarrhea, while left-sided tumors are usually detected later and
may present as bowel obstruction.
- FINAL DIAGNOSIS
Colon cancer is caused by the abnormal growth of epithelial cells which form the lining
of the colon or rectum. These small growths (known as polyps) are often benign, although some have the
potential to develop and become cancerous. It is estimated that up to two thirds of colorectal polyps are
pre-malignant and associated with a risk of colorectal cancer.
Screening and awareness can reduce mortality of colorectal cancer by detecting and
removing polyps before they become cancerous, or by discovering the cancer at an earlier stage, where
treatment has a higher success rate. However, there are often no initial symptoms and the cancer may
already have spread to other parts of the body by the time the patient is diagnosed.
Colorectal cancer is diagnosed in over 1.2 million people globally each year; it is the
second most common cancer in women and the third most common cancer in men. The disease is
responsible for approximately 609,000 deaths each year (8% of all cancer deaths), making it the fourth
leading cause of cancer death after lung, stomach and liver cancers.
Cancer statistics often use an overall 5-year survival rate to give a better idea of the
longer term outlook for people with a particular cancer. The overall 5-year survival rate for colorectal
cancer patients is 65%, although this differs greatly depending on how advanced the cancer is. The 5year survival rate for a patient diagnosed with stage I or II colorectal cancer, where the tumor is
localized to the colon, is up to 90%. Approximately two fifths of patients are diagnosed at this stage.
However the 5-year survival rate for patients diagnosed with stage IV disease, once the cancer has
metastasized to other organs, is only 12%.

In general the current treatment options for colorectal cancer are surgery, chemotherapy,
and biological therapies. Radiotherapy is not often used to treat metastatic colorectal cancer due to side
effects, although it can be used after surgery to destroy any residual cancer cells.
- PATHOPHYSIOLOGY OF COLON CANCER
Colon cancers arise from dysplastic adenomatous polyps in the majority of cases. There
is a multistep process involving the inactivation of a variety of tumor-suppressor and DNA repair genes,
along with simultaneous activation of oncogenes. This confers a selective growth advantage to the
colonic epithelial cell and drives the transformation from normal colonic epithelium to adenomatous
polyp to invasive colorectal cancer. A single germline mutation in the adenomatous polyposis coli (APC)
tumor suppressor gene is responsible for the dominantly inherited syndrome familial adenomatous
polyposis. Clinical expression of the disease is seen when the inherited mutation of one APC allele is
followed by a second hit mutation or deletion of the second allele.
- Non-modifiable
- Genetic factors
Age,
Gender, Race
Loss of key tumor suppressor genes
and activation of oncogenes
- Modifiable
-Diet and Exercise
- Environmental
Alteration of colonic mucosa cell
- factors(stress)
division
-Obesity, Smoking,
Alcohol
Asbestos
Formation of polyps, growing slowly
into malignant tumors,
asymptomatic for long periods of
time
Left Side - circumferential
- Right Side - tumor grows
and can obstruct the bowel
- outwards from one location
in the bowel wall
-

Presents with anemia

- Rarely causes obstruction
of feces
Unexplained
Feeling of fullness
-weight loss
Constipation
Cramping
abdominal pain
-

Usually no signs and/or symptoms

Fatigue and
weakness

Bloody black,
tarry or bright red
stools
Figure 1. Pathophysiology of Colon Cancer

Diarrhea

Rectal pain