USMLE STEP2 CS Case 37 (Bloody Stool) 英語プレゼン例

First Aid for the USMLE STEP 2 CS Clinical Skills 6th Editionの、Case 37: 55-Year-Old Man With Bloody Stoolを基にプレゼン例を書いてみました。僕はシンガポールでしか臨床実習をしたことがないので、アメリカで使われてる英語とは少々異なるかもしれませんがご了承ください。

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Case 37: 55-Year-Old Man With Bloody Stool

Opening Statement

Patient is a 55 year old caucasian male with positive family history of colorectal cancer, presents with blood in stool for 1 month, associated with weight loss and change in bowel habits.

History of Presenting Complaint

Patient has been noticing blood in his stool for the past month. The blood is mixed with the stool, and the color is bright red.

Patient also reports a recent change in bowel habits. Patient normally only has bowel movements 2 to 3 times per week, but he has been having diarrhea over the past 2 days. The patient also reports tenesmus.

The patient also reports recent weight loss of 5kg over the past 6 months.

Otherwise the patient doesn’t report any symptoms, such as abdominal pain, fever, urinary symptoms, nausea and vomiting.

Past medical history wise, the patient had his hemorrhoids resected 4 years ago, and recently completed a course of amoxicillin 4 weeks ago due to bronchitis.

Drug history wise, patient currently does not take any medications, and has no drug allergy.

Family history wise, patient’s father passed away due to colorectal cancer at age 55.

The patient does not smoke or drink.

The patient works as a lawyer and lives with his wife.

Physical Examination

On general inspection, the patient is alert, comfortable, and not breathless. Vital signs are stable. Physical examination findings are largely unremarkable. Heart sounds normal S1/S2, bilateral breath sounds, abdomen is soft and non-tender, no organomegaly and bowel sounds are positive.

Summary

In summary, my patient is a 55 year old caucasian male with positive family history of colorectal cancer, presents with blood in stool for 1 month, associated with weight loss and change in bowel habits. Physical examination was largely unremarkable.

Differentials

With that, my first differential is colorectal cancer, due to bloody stools, weight loss, and positive family history of colorectal cancer.

My second differential is hemorrhoids due to his history of hemorrhoids.

My third differential is Clostridium difficile colitis due to recent antibiotic use.

Investigations

I'd like to run some investigations to confirm my diagnosis and to guide my management. 

First, I'd like to order some blood tests. I'd like to order complete blood count (CBC) to check for any anemia. I'd also like to order renal panel (basic metabolic panel / CHEM-7) to evaluate the patient's kidney function as the patient is likely to get a contrasted CT scan. 

Imaging wise, I'd like to perform a contrasted CT abdomen/pelvis to look for any masses, and to stage his cancer. I'd also like to refer the patient for colonoscopy.