[Verified Answer]: Chief Complaint “Blood in stool for the…

Chief Complaint “Blood in stool for the past 4 months” History of Present Illness: A 52-year-old woman with obesity and hypothyroidism presents to an urgent care clinic affiliated with her PCP’s practice for rectal bleeding for the past 4 months. Initially, it happened about once a week during a bowel movement but was currently occurring daily with all bowel movements. She describes the blood as approximately 1 teaspoon, dark red, and mixed in the stool. She denies any associated rectal or abdominal pain, and her bowel movements are regular every day without change, although they do seem thinner, which she attributes to starting a low-carbohydrate diet 4 months ago. She relays a history of internal hemorrhoids after the birth of her daughter 20 years ago, with rare bleeding throughout the years that always improves within a day of applying over-the-counter hemorrhoid cream. Despite using this cream daily now, there has been no improvement in current symptoms. Though she was referred for colonoscopy screening at age 50, she never scheduled it because she was “afraid of the prep” and did not want to miss a whole day of work. She states she called her regular PCP 3 months ago about her bleeding. “He told to me that my insurance allows me to see the gastroenterologist without a referral, so I should go there and get a colonoscopy done.” The procedure is scheduled in 3 weeks, the earliest available for the “routine screening” referral sent. The patient asked whether “the take-home test” or a “virtual colonoscopy” could be ordered today for quicker results. Review of Systems: The patient endorses fatigue and weight loss of 12 lbs in 4 months, which she attributes to dieting, and occasional night sweats, which she attributes to menopause. She denies fever or chills. She endorses increasing SOB when walking upstairs or hills for the past month but denies any chest pain, palpitations, or syncope; endorses dizziness when standing up quickly but denies headache, weakness, or paresthesia; denies cough, wheezing, or hemoptysis; denies anorexia, heartburn, nause(a)/(v)omiting, diarrhea, or melena; denies any dysuria, hematuria, vaginal bleeding or discharge, or pelvic pain; denies any increased bruising or swollen lymph nodes; denies any skin rashes, lesions, or itching; and denies insomnia, anxiety, or depression. Relevant History The patient has struggled with obesity since her pregnancy at age 32, after which she was diagnosed with hypothyroidism. She has taken levothyroxine 112 mcg daily for 20 years but takes no other medications or supplements. She has no prior history of heart, lung, GI, or bleeding disorders, and she has no prior surgeries or hospitalizations. Her parents are alive and healthy in their late 70s; she believes her maternal grandmother died in her 60s of “some kind of stomach cancer.” There is no family history of heart disease, diabetes, or bleeding disorder. She is married and sexually active. She does not smoke or use any recreational drugs. She drinks 2 glasses of wine every night with dinner. Allergies: None. Medications: Levothyroxine 112 mcg QD. Physical Examination: Vitals: T 37.2deg C (99.0deg F), P 98, R 18, BP( 110)/(62), SPo2 97%, HT 157.5 cm (62 in.), WT 91.2 kg (201 lbs), BMI 36.0. General: Well-developed, obese Caucasian female; A&O; all vital signs stable; in no acute distress. Psychiatric: Broad affect euthymic mood, fluent speech, average insight. Skin, Hair, and Nails: Warm and dry, pallor of skin noted, nail beds, and conjunctivae. No jaundice or rashes present. No abnormal findings with hair or nails. Lungs: Clear to auscultation bilaterally with no adventitious sounds. Good effort with no accessory muscle use. Heart: RRR with no murmurs, gallops, or rubs. Abdomen: Protuberant noted with central obesity. Normal active bowel sounds in all quadrants with no bruits noted. Soft, non-tender, non-distended; no masses, organomegaly, or hernia present. Genita(l)/(R)ectal: Genital exam deferred; rectal exam shows normal sphincter tone, no fissures noted, visible small non-tender non-thrombosed external hemorrhoid visible at 6 o’ clock, and a small non-tender internal hemorrhoid at 9 o’ clock. Brown hard stool and gross blood noted in vault, which is guaiac-fecal occult blood test positive. Extremities: No edema, clubbing, or cyanosis. Radial and dorsalis pedis pulses 2+ bilaterally. Neurologic: Gait steady; no tremors, no focal deficits. Clinical Discussion Questions 1. What is the differential diagnosis? 2. What is the most likely diagnosis? Why? 3. Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis. 4. Should test(s)/(i)maging studies be ordered? Which ones? Why? Think about test(s)/(i)maging beyond the primary care setting as well. 5. What are the next appropriate steps in management? 6. What is the level of understanding of this diagnosis among noninfectious disease providers? What is the treatm