GI LOCAS EXAMINATION

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GI LOCAS EXAMINATION
Jeni Ketheswaran Natalie Foy
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Introduction

• You WILL be fine!!!
• Dont panic!
• If you do panic in a station You will STILL be
  fine!!
• Practice lots in hospital feel natural
  performing examination in the exam

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The 3 Golden Laws to Locas Examination
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• 1st Law
• Before you even touch the patient
• 2nd LAW
• Normal examination
• 3rd LAW
• Any extras
• Rounding off the consultation

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1st LAW

• Before you even touch the patient
• Introductions
• Introduce
• Check identity
• Explain procedure
• Gain consent
• Wash hands
• cont...

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1st Law cont...

• Position and exposure
• I would like you to take your top off please and
  lie flat on the bed with your hands by your side
  and just a pillow if thats ok for you?
• Use your common sense though!
• Can they physically lie flat?
• Help them if they need help!
• Be compassionate!!
• Can explain ideal position / exposure to examiner
• ideally from nipple to knee will preserve
  their modesty...

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2nd Law

• Normal examination
• ALWAYS start from the end of the bed...
• What do you notice around the bed?
• Drip / Blood transfusion bag
• What is obvious on the patient?
• Scars / Stomas / NG tube

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2nd Law

• Normal examination
• Inspection
• Palpation
• Percussion
• Ascultation

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2nd Law

• Inspection
• Hands Note ves and significant negatives (3)
• Pluse
• BP
• Eyes
• Mouth
• CHEST
• Spider Naevi
• Gynacomastia
• Abdomen

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2ND Law

• Palpation
• ASK ABOUT PAIN!
• KNEEL DOWN
• WATCH FACE
• System that works for you
• General start away from pain
• Describe any masses as you find them
• Liver, spleen, kidneys, ascites/shifting dullness
• Abdominal aortic aneurysm

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2nd Law

• Percussion
• System that works for you
• May want to percuss organs individually after
  palpation
• Note hepatomegally percuss to top of liver
  may just be pushed down from hyperinflated chest
• Resonant over bowel
• Auscultate
• Bowel sounds present?
• Bruits
• Aortic, renal, iliac

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3rd Law

• Any extras
• Hernias
• Ask patient to cough
• Watch abdomen
• Place hands over L R groin and feel for
  impulse
• If lump or suspicious of hernia continue to do
  full hernia examination
• Abdominal aortic aneursym

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3rd Law

• Say to complete my examination I would like to
• Examine the external genitaila / hernial orifices
• Perform a rectal examination
• Perform a vaginal examination
• Dipstick the urine
• Round off consultation
• Cover up patient / let them get dressed
• Thank the patient
• Summarise findings

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What will come up?!!

• Ask friends in year above / doctors etc etc!
• Common findings and questions last year / in
  previous years
• Hernias
• Differential diagnosis/ complications /
  management options / risk factors
• Stomas
• Type / temporary / permanent / possible cause /
  complications
• Scars
• Name / differential diagnosis

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Other findings...

• Hepatomegaly and jaundice
• Causes / investigations / managment
• Splenomegaly
• Causes (surgical sieve!) how to differentiate
  from enlarged kidneys / investigations /
  complications / management / what vaccines will
  they need after splenectomy?
• Hepatoslenomegally
• Causes probably will be cirrhosis with
  associated portal hypertension in LOCAS
• Ascites
• Causes / investigation / management / 5 Fs of
  abdominal distention
• Masses ...
• Areas of tenderness...

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You find a mass or tender area

• Dont panic about a finding which you are unsure
  about!
• Use surgical sieve to think of a list of
  differentials in that area
• You all know where the organs are found what
  organ is nearest to that location?
• Dont forget other structures in the area skin
  / subcutaneous tissue / fat / muscle
• Describe the mass as you would any mass
• I SPED PAST CHIMES??!!
• PCSSM
• Position . Consistency . Shape . Size . Mobility

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ORGANOMEGALY

• Think of Surgical sieve. I.e. ways to remember
  causes.
• vitamin D vascular, infection, trauma,
  autoimmune, metabolic, inflammation, neoplasia,
  degeneration
• Or working your way down the anatomical planes
  for Groin lumps skin ?fat?muscle etc
• Or Within the lumen, Within the wall, Outside the
  wall

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Key -abc causes of a mass - abc causes of
acute pain
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Scars
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Subcostal - Cholestystectomy
Midline - Gastroduodenal - Pancreatic -
Splenic surgery
Paramedian - Laparotomy
Nephrectomy
Midline - classical caesarian section -
Hysterectomy
Appendicectomy
Inguinal hernia repair
Suprapubic / Pfannenstiel - Caesarian section
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Stomas
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STOMAS

• A stoma is an artificial opening of the abdomen
  into the intestine or bladder, made surgically
  and covered by an adherent collection bag to
  allow the bypassing of faeces or urine.
• Most people have a Stoma nurse to help them.

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STOMAS

• can be temporary or permanent
• classified according to the section of intestine
  or urinary tract that joins the abdominal wall
• Examples
• Ileostomy an opening allowing the ileum to be
  brought through the abdominal wall, allowing
  faeces to bypass the colon (large
  bowel).Colostomy surgery involves part of the
  large bowel (colon) opening through the abdominal
  wall, allowing faeces to bypass the anus into a
  bag attached to the skin.Urostomy (urinary
  diversion or ureterostomy) This is where the
  ureter is brought through the abdominal wall to
  bypass the bladder, allowing the passing of urine.

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STOMAS
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Risk Factors

• Inflammatory bowel disease (including Crohn's
  disease and ulcerative colitis)
• Colorectal cancer
• Diverticular disease
• Accidental damage to bowel wall
• Urostomies (rare) may be caused by cancer, or
  pelvic and abdominal surgery

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Colostomy
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Ileostomy
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Urostomy
The operation is sometimes called an 'ileal
conduit' (pronounced eye-lee-al con-dwee).  This
is because the surgeon is most likely to use a
bit of your small bowel (ileum) to carry urine
from the ureters to the urostomy bag.
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Complications

• Ischaemia of terminal bowel
• Obstruction of bowel
• Skin erosion and discomfort
• Parastomal hernia
• Stomal stenosis
• Retraction of spout of an ileostomy
• Bowel prolapse through the stoma

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Arteriovenous Fistula

• An arteriovenous fistula is an abnormal channel
  or passage between an artery and a vein.
• For haemodialysis.
• Can hear a buzzing (bruit)
• and can feel the thrill.

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HERNIAS

• Protrusion of a tissue, structure, or part of an
  organ through the muscular tissue or the membrane
  by which it is normally contained.
• Most likely to get Inguinal or Femoral
• Inguinal -more common in men than women, but
  femoral hernia more common in women.
• Inguinal is either DIRECT or INDIRECT.

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Types of Hernia
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Inguinal hernia

• Mid-inguinal point
• Femoral artery / pulse
• ½ way between pubic tubercle and ASIS
• Mid point of the inguinal ligament
• Deep ring
• ½ way between pubic symphysis and ASIS
• Direct and indirect

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GOOD LUCK!!!

• PRACTICE IN THE WARDS!!
• See lots of patients
• Ask for help especially from F1S /f2S
• Try Will Westons website
• http//www.willweston.net/revisionnotes/