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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...
 

2121115

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It is hard to appreciate this now, but be thankful that the attendings care enough to kick your ass a little bit. It is hard to comment directly on the situations you describe since I'm not in your program and I don't know how it is there, but just roll with it and keep working hard.
 

TMZ2007

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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. [SNIP] Maybe Its just too late and I'm just thinking too much about this...
I do know that you should be cautious in calling mucosal/lamina propria inflammation in general when a lymphoid follicle is nearby. The infiltrate could be just the white cells spreading/leaking from the follicle into the surrounding tissue, and not representative of a destructive process. (PGY1, a whopping 8 weeks' surg path experience so far.)

Indeed, you are likely thinking too much about this! As long as you are not getting written up/put on probation for being a *******, I would not worry too much. Our job is to learn, not practice independently. If that means you look foolish occasionally, ok. Keep reading and grossing and looking at cases, and everything should be fine.
 

levels x3

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The question of clinical history is an interesting one. There are people who believe that history should be ignored, and that all you need is the morphology. Others rely heavily on the clinical history to guide their thinking. For what it's worth, I fall into the latter group. I'm not suggesting you ignore what's on the slides, but I like to know that what I'm seeing matches what the history suggests I should be seeing.
 

yaah

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Everybody goes through that stage in residency - where you have started to learn enough to get past the basics and are trying to formulate your own diagnoses. It's like a second hump to get over. The third is when you finally have to be on your own and make the final call.

HCL and other neoplasms can be primarily red pulp diseases, that is probably what your attending is getting at. And clinical history is crucial but it isn't everything. The clinical history most helps after you have formulated your initial diagnostic opinions, to either confirm them or to make you realize you might be on the wrong track. Getting the clinical history first and then working to make the findings fit your impression can lead to erroneous assumptions.

You are not falling behind, you are learning to synthesize information and make histologic distinctions. The above poster is right, it is good that you have an attending who is trying to ensure you are learning. In a lot of programs you might not get that feedback, but you are better off when you do (even when it bruises your ego).
 

malchik

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Agree with Yaah, I like looking at the history after looking at the case and coming up with a differential.