- Joined
- Mar 26, 2010
- Messages
- 31
- Reaction score
- 3
Today I didn't know that you can't call cryptitis and crypt abscess as part of possible Crohn's disease in a rectal biopsy when the crypts being examined lay adjacent a lymphoid follicle. In the same slide, there was an area showing ulcer formation in the mucosa, and the clinical history described the biopsy specimen taken at "apthous ulcer". I was entertaining the possibility of Crohn's the the morpholgical finding of patchy acute inflammation and possible granuloma formation (which were actually just light zones in germinal centre follicles), and that the patient was 36 and indication for biopsy was "diarrhea and abdominal pain" I am nearing the end of my second year in a few months. Have I fallen behind?
Also interesting today...I was scolded for relying too heavily on history and less on morphology in assessing the cases...we had a 798g spleen in a 46 yo woman with chronic pancreatitis. I did not have a chance to preview the case but in the few seconds looking at it with the attending (and not letting him on to the fact that I hadn't gotten to the case during my limited preview time!) I saw that there was primarily red pulp expansion and the white pulp appeared unremarkable. The patient also had low HCT and low platelet count, and had recently had a peripheral blood smear evaluation whose comment read that the cause of the anemia and thrombocytopenia were unclear from morphologic examination of the smear and there was no evidence of a microangiopathic hemolytic anemia. I remembered that patients with chronic pancreatitis are prone to splenic vein thrombosis due to its course posterior to the pancreas, and thus may develop splenomegaly and subsequent consumptive coagulopathy. The attending was mad when I did not verbalize the possibility of lymphoma or leukemia when he asked me the differential. I was thinking...those should not be in the differential given this history and morphology. myeloproliferative diseases, especially PMF or CML, may show splenomegaly. Also, Hairy cell leukemia classically shows splenomegaly, and CLL, or even T-LGL leukemia may show splenomegaly. ITP may show splenomegaly. Because none of these diseases were things I considered seriously, I said I was more impressed by the clinical history. When I checked the surgery procedure note, it became clear that the surgeon's impression was indeed splenic vein thrombosis as a result of pancreatitis, now resulting in splenomegaly. I was not sure if my attending was being unreasonable...I don't know if its just that he's really hard on me. I didn't dare verbalize this was all going through my head because I didn't want to sound like I was arguing with him. Is this experience unique or do other pathology residents have similar experiences of tension with the attending at sign out making you hesitant to be especially vocal in your thought processes? Was this attending being malignant? I felt like given my impression, relying on clinical history in this case was more important. Maybe Its just too late and I'm just thinking too much about this...
Also interesting today...I was scolded for relying too heavily on history and less on morphology in assessing the cases...we had a 798g spleen in a 46 yo woman with chronic pancreatitis. I did not have a chance to preview the case but in the few seconds looking at it with the attending (and not letting him on to the fact that I hadn't gotten to the case during my limited preview time!) I saw that there was primarily red pulp expansion and the white pulp appeared unremarkable. The patient also had low HCT and low platelet count, and had recently had a peripheral blood smear evaluation whose comment read that the cause of the anemia and thrombocytopenia were unclear from morphologic examination of the smear and there was no evidence of a microangiopathic hemolytic anemia. I remembered that patients with chronic pancreatitis are prone to splenic vein thrombosis due to its course posterior to the pancreas, and thus may develop splenomegaly and subsequent consumptive coagulopathy. The attending was mad when I did not verbalize the possibility of lymphoma or leukemia when he asked me the differential. I was thinking...those should not be in the differential given this history and morphology. myeloproliferative diseases, especially PMF or CML, may show splenomegaly. Also, Hairy cell leukemia classically shows splenomegaly, and CLL, or even T-LGL leukemia may show splenomegaly. ITP may show splenomegaly. Because none of these diseases were things I considered seriously, I said I was more impressed by the clinical history. When I checked the surgery procedure note, it became clear that the surgeon's impression was indeed splenic vein thrombosis as a result of pancreatitis, now resulting in splenomegaly. I was not sure if my attending was being unreasonable...I don't know if its just that he's really hard on me. I didn't dare verbalize this was all going through my head because I didn't want to sound like I was arguing with him. Is this experience unique or do other pathology residents have similar experiences of tension with the attending at sign out making you hesitant to be especially vocal in your thought processes? Was this attending being malignant? I felt like given my impression, relying on clinical history in this case was more important. Maybe Its just too late and I'm just thinking too much about this...