Tuesday, October 10, 2017

USMLE Step 3: CCS Inflammatory bowel disease checklist

These are just my notes / checklist from the UW case 3. This post will not make sense to you if you are not preparing for CCS.

Case begins - Young patient with bloody diarrhea.

Check vitals first!

- Physical examination
- Stool for microscopy, ova, parasites, leukocytes, fat, gram stain, culture, C diff toxin
- Loperamide, Dicyclomine, low residue diet*

You know it's IBD - order specific tests.

- Flexibile sigmoidoscopy (Do not do colonoscopy in acute flare because of risk of perforation)
- Rectal biopsy

Results confirm UC

- Order Mesalamine rectal

Schedule appointment in two weeks, patient gets better.

- Discontinue diet
- Discontinue loperamide, dicyclomine
- Order Mesalamine oral (You taper 4-6 weeks but the option isn't available in CCS)
- Counsel (smoking, medication side effects)
- Order colonoscopy (Just to have a baseline record) **

Diagnosis: Ulcerative colitis

Case ends.

* What is a low residue diet?
The low residue diet has traditionally been used to reduce fecal volume in a number of situations: to treat diarrhea, keep wounds free from stool, promote wound healing in patients with decubitus ulcers or those who have undergone rectal surgeries.
Low residue or low fiber diet prescriptions are common in clinical practice for symptomatic IBD patients, despite a lack of research on their efficacy. If these diets are utilized there should be careful follow up, and if symptomatic relief does not occur, then restrictions should be lifted.
Source: https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-July-15.pdf

** Screening guidelines: The American Cancer Society recommends initial screening (i.e., eight years for pancolitis, 12 to 15 years for left-sided disease) and follow-up examinations should be done every one to two years. Colonoscopy should include random mucosal biopsies of the colon every 10 cm.

That's all!

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