1. Medicine Grand Rounds Clinical Vignette Becky Naoulou, MD PGY-2 May 28, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. Patient is a 60 year old man with juvenile diabetes and ESRD who presents for a screening colonoscopy. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Patient was undergoing evaluation for a kidney transplant. Was referred for a screening colonoscopy as part of the pre-transplant work-up. He denies any complaints. He never had a colonoscopy before. Reports he has regular daily bowel movements. Denies any change in stool caliber or color. Also denies red blood or black stool. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: Juvenile DM, ESRD on dialysis Past Surgical History: denies Social History: Lives alone, works as a carpenter. Denies tobacco, alcohol and illicit drug use Family History: no family history of GI malignancy. His brother may have had polyps, gets frequent colonoscopies but patient does not know further details. No Known Drug Allergies Medications: glargine at bedtime, aspart sliding scale U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: White man, appearing stated age, no acute distress. Vital Signs: T: 98.6 BP:116/76 HR:70, RR:14 and O2 sat:100% on RA Rectal exam with brown stool, no masses or hemorrhoids Remainder of the physical exam was also normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC, hepatic panel, and coagulation studies were within normal limits Basic metabolic panel remarkable for a creatinine 3 (at patient’s baseline) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Colonoscopy A colonoscopy was performed which had good prep to the cecum, confirmed by appendix and the ileocecal valve. In the sigmoid colon, there was a large pedunculated polyp 3 cm in size. This was resected with a hot snare polypectomy and sent to pathology. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Tubulovillous Adenoma with High-Grade Dysplasia Pathology/Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS