{"id":2307,"date":"2010-04-07T14:56:14","date_gmt":"2010-04-07T18:56:14","guid":{"rendered":"https:\/\/www.med.unc.edu\/dms\/dms\/fax-journal\/past-issues\/2009-2010-edition\/a-second-opinion-by-rachel-hines\/"},"modified":"2018-12-04T15:03:13","modified_gmt":"2018-12-04T20:03:13","slug":"a-second-opinion-by-rachel-hines","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/dms\/past-issues\/2009-2010-edition\/a-second-opinion-by-rachel-hines\/","title":{"rendered":"A Second Opinion by Rachel Hines"},"content":{"rendered":"
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A Second Opinion by Rachel Hines<\/strong>\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0I have already gone through my rituals with five or six patients this morning. I made conversation, asked the right questions, instinctively re-deepened my drawl, and found a couple new neutral phrases to use after completing the various elements of the patient history and physical exam: \u201cok,\u201d\u00a0\u201cthanks,\u201d\u00a0\u201calright,\u201d\u00a0\u201call done.\u201d\u00a0 Sometimes I would slip up and says something like \u201csounds good\u201d\u00a0 after auscultating a patient\u2019s heart or lungs. Then I worried Dr. Alston would come in after me and tell the patient that actually, it doesn\u2019t sound good. \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Again, I pull a chart from an exam room\u2019s door. Bass. <\/em> (\u201cHey there Mrs. Bass!\u201d) 1923. <\/em> (That makes her 86.) Follow-up. <\/em> (I bet for some permutation of high cholesterol, diabetes, and\/or hypertension.) Blood pressure 150\/95. <\/em>(Bingo.) Weight 178. <\/em> (\u201cI see you\u2019ve lost a couple pounds \u2013 that\u2019s hard to do over the holidays!\u201d) Total cholesterol 198. HDL 53. <\/em>(\u201cYour cholesterol is doing great!\u201d) Hemoglobin 10.3. <\/em> (\u201cIt looks like you\u2019re still a little anemic.\u201d) Last note dated 10\/3\/09 from Dr. Alston reads: Mrs. Bass is a well-appearing, pleasant woman who presents today for routine follow up. She has no complaints. Previous labs revealed progressive anemia and stool sample was heme positive. I discussed with her the need for colonoscopy to identify sources of blood loss, including a GI malignancy, but she was not interested in having a colonoscopy at this time. The patient stated that she understood that in not having a colonoscopy, we could not rule out many causes of blood loss, including malignancy. <\/em>\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Mrs. Bass\u2019\u00a0patient demographic sheet is tagged with a handwritten sticky note that reads \u201ccolonoscopy\u201d\u00a0and I assume that this is Dr. Alston\u2019s self-reminder to further discuss the issue with her. I knock and, without waiting for a response, open the door to the room. Mrs. Bass has been waiting and I greet her with a smile and my usual introductions as I take a seat to face her. She has white hair and loose wrinkles on her face, beyond the telltale patterning of smiles and squints into the work of gravity and disrupted collagen. Overweight in a way most would not label on account of her age, her lower stomach bulges disproportionately beneath a clean striped shirt. It is tugging her pants up just high enough so that an inch of calf is exposed above her socks. Her socks match her pants which match the stripes. \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0Mrs. Bass reminds me of my grandmother. She has \u201cno acute complaints\u201d\u00a0 despite being 86. She tells me that she cooks, she cleans, she hosts her children and their families at her home. This is a patient with a \u201chigh quality of life.\u201d She diligently opens her plastic pill organizer each morning after breakfast and takes a palmful of requisite drugs, though she would prefer not to. She knows their names and dosages when asked, even if she sometimes forgets what each is for. Simvastatin, Atenolol, vitamin D with calcium. Mrs. Bass is \u201ccompliant.\u201d Her chart reveals that her husband died recently, yet she is not taking antidepressants like many other recently widowed patients. I suppose in her case, bereavement did not turn pathologic. \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0It is easy to speak with Mrs. Bass, and \u201cpleasant\u201d\u00a0actually seems to be an apt adjective in her case. She understands my questions and provides responses with an appropriately small amount of tangential information. For example, when I ask her if she has noticed any blood in her stool recently, she says: \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cWell, I think there might be.\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cHow often have you noticed it?\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cOh, probably most times I go to the bathroom.\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cCan you describe what it looks like? For example, is the blood bright red or dark?\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cWell, that\u2019s the thing. It looks kind of like raspberries. And I eat frozen raspberries at least once a day. I love raspberries.\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cIs the raspberry-looking stuff part of the stool or is it separate?\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u201cIt\u2019s separate, just in the bowl with it, so that\u2019s why I\u2019m just not sure whether it\u2019s actually blood or not.\u201d\u00a0\u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0I stop for a moment and picture her stool. I consider what I know about bowel movements, one of the more artfully described phenomena in medicine. Common descriptors include \u201csausage or snake-like,\u201d\u00a0\u201cfluffy,\u201d\u00a0 and \u201clumpy.\u201d\u00a0Stool can include \u201coccult blood.\u201d\u00a0Doctors refer to \u201cmelena\u201d and \u201csteatorrhea\u201d like Inuits describing snow. I am tempted to ask Mrs. Bass if she could draw it for me or at least describe how it would appear on a menu. (A mousse with raspberry drizzle? Or more like an \u00e9clair with fresh berries?) Instead, I tell her that it would be hard to tell if it is bloody without more tests and ask her if she has given any more thought to having a colonoscopy. \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0She has, and she still does not want one. She refers to a recent article that indicated people over 80 don\u2019t need colonoscopies and tells me she mailed a copy to Dr. Alston when it was first suggested that she get one. I know the research to which she is referring \u2013\u00a0and by \u201cknow,\u201d\u00a0I mean \u201cremember hearing about.\u201d\u00a0I think it was when we spent a few days before Thanksgiving discussing geriatrics. From what I recall, current guidelines recommend against screening colonoscopies for people over 80 because they are more likely to do harm than help. Everything in old people gets fragile \u2013 the tube of colonic muscles, blood vessels, dendrites, skin, their whole bodies. Bowel perforations happen. Insert an endoscope and Pop! goes the intestinal wall. \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0I imagine that polyps, little cellular seaweeds, are growing into Mrs. Bass\u2019\u00a0colon. Their stalks and spherical buds extend into the lumen of the large intestine, bending with the flow of most feces, bleeding if their little bobble heads are hit by something solid. That makes them different from seaweed. You see, Mrs. Bass, we could solve all this with a snip and sizzle, a cut and cautery if you\u2019ll simply let us sedate you and put a camera up your colon. Given time, the polyps can sprout elsewhere, preferring liver and pelvic neighborhoods. Excuse me, ma\u2019am, you may have some colon in your uterus. <\/p>\n

I silently quiz myself. Which of the following is most likely responsible for heme positive stool in a geriatric patient? \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0a) Metastatic colorectal carcinoma <\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0b) Adenomatous polyp <\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0c) Diverticulosis <\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0d) Diverticulitis <\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0e) Internal hemorrhoids \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0I rule it down to b) or c) and am feeling pretty satisfied with myself when I hear Mrs. Bass exhale. Surrendering her conviction, she meets my eyes and asks, \u201cWhat do you <\/em> think I should do?\u201d \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0This is not part of my routine. I have had patients ask me questions like, \u201cWhat do you know about Lipitor?\u201d\u00a0or \u201cAre these red bumps on my arms normal?\u201d\u00a0but her question is different. I think she is asking me to evaluate her quality of life as a person, beyond performing activities of daily living and personal maintenance. Is the procedure worth it? Is she <\/em>worth it? The risk of bowel perforation, chemotherapy, thousands of dollars. She had thought not, but is uncertain. Doctors see uncertainty and order tests to be sure but I am not a doctor and I too am uncertain and that is valuable. \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0May I please have the question in the form of a brief clinical vignette? \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0An 86 year old patient with a history of hypercholesterolemia and hypertension presents with heme positive stool and worsening anemia. She is otherwise healthy, is well-educated, maintains an independent lifestyle, and was recently widowed. What is the most appropriate next step in the diagnostic management of this patient and the associated major concern? \u00a0<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0a) Colonoscopy; bowel perforation <\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0b) Barium enema; low yield results at high cost to the patient <\/p>\n