History & Examination with common OSCE examples for Finals

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Gastrointestinal System

• History Examination with common OSCE examples
  for Finals

By Maryam Haneef, FY1 Medicine
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History

• Abdominal pain
• SOCRATES
• Peptic Ulcer disease
• dull, burning, gnawing, epigastric, relief with
  food, episodic
• Cannot tell if GU or DU with just history!
• Pancreatic
• Steady, epigastric, relief sitting forward,
  radiates to back, vomiting
• Biliary
• Severe epigastric pain, episodic (biliary
  obstruction-biliary colic)
• Shift to RUQ, more severe (cholecystitis)
• Hepatic
• Dull ache, RUQ
• Bowel
• Colicky
• Periumbilical, frequent cycles of pain (small
  bowel)
• Longer period between pain (colonic)
• Vomiting, constipation, distension (obstruction)

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ABDO PAIN (cont.)

• Appendix
• RIF pain, stabbing to dullache, started
  periumbilical? Guarding, rebound tenderness
• Oesophagitis
• Retrosternal discomfort/burning
• heartburn
• Travels up throat, after meals, bending/lying
  supine
• water brash and sour taste in mouth
• Worse alcohol, chocolate, caffeine, fatty meals,
  anti-cholinergics, calcium channel blockers
  (reduce LOS tone)

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Nausea and Vomiting

• GI infection
• Obstruction
• Small bowel (volvulus, intersusseption)
• Gastric outlet (PUD)
• Pregnancy
• Drugs
• Opiates, digoxin, chemo
• Gastroparesis
• Diabetes mellitus, recent gastric surgery
• Acute hepatobiliary disease
• Biliary colic, cholecystitis, hepatitis
• Pancreatitis

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Vomitus

• Coffee Ground
• PUD
• Bilious
• Patent passage between stomach and duodenum
• Blood streaked
• Mallory-Weiss
• Bleeding ulcer
• Stomach Ca

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Dysphagia

• Rule out painful swallowing (ODYNOPHAGIA)
• Infectious oesophagitis (candida, herpes)
• Peptic ulcer of Oesophagus
• Oesophageal perf.
• Solids/liquids
• Progressive deterioration solid to liquid
  Stricture
• Ca
• Extrinsic pressure retrosternal goitre, lung Ca
• Oesophageal web, benign stricture
• Difficult initiating swallow/regurgitation into
  nose/choking
• Pharyngeal neurological (MND, MG)
• Food sticking
• Point out where
• Intermittent/initial swallows Oesophageal spasm
• Solids and liquids Achalasia
• Neck bulge/gurgling pharyngeal pouch

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Bleeding

• Hameatemesis
• Proximal to duodenum
• Sx PUD? (could be acute peptic ulcer, no Hx pain)
• Hx repeated vomiting/retching (Mallory-Weiss)
• Acute setting Large volume, pt unwell, Hx Liver
  disease (variceal bleed)
• Others gastric Ca, vascular anomolies
• Melaena
• Jet black stool
• Bleed from upper GI tract (occasional small
  R-sided colonic or small bowel lesions)
• Fresh PR bleed (Haematochezia)
• On top of stool/in toilet bowl/on toilet paper
• Haemorrhoids/anal fissures
• Diverticular disease
• Mixed with stool
• Ulcerative colitis, colorectal Ca

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Jaundice

• Yellow discolouration skin/sclera
• Pale stools, dark urine, pruritis
• Obstructive/cholestatic jaundice
• Short duration, malaise, fever, anorexia
• Viral hepatitis (recent travel, IVDU, sexual Hx)
• Abdo pain
• Episodic, colicky, RUQ gallstones
• Dull, persistent epigastric or central radiating
  to back pancreatic Ca
• Fever or rigors cholecystitis/cholangitis
• FH recurrent jaundice
• Haemolytic anaemias, Gilberts

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Diarrhoea

• Defined as passing of gt300g loose stool per day
• Secretory
• High volume, persists on fasting, no pus/blood,
  not fatty
• Infection E.coli, staph aureus, vibrio cholera
• Hormonal carcinoid, Zollinger-Ellison
• Villous adenoma
• Factitious diarrhoea laxative abuse
• Osmotic
• Large volume, stops by fasting
• Medication lactulose, Mg antacid
• Lactose intolerance
• Gastric surgery

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Diarrhoea (Cont.)

• Abnormal intestinal motility
• Thyrotoxicosis, IBS, Addisons
• Exudative
• Inflammation in colon, small volume stool with
  blood/mucus
• IBD, colon Ca
• Malabsoprtion
• Steatorrhoea pale, fatty, v.smelly, floaters!
• more than 7g fat in 24-hour stool sample
• Chronic pancreatitis, bile salt deficiency (liver
  disease, extrahepatic obstruction), bacterial
  overgrowth, terminal ileal disease

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Constipation

• Infrequent passage of stool, hard stool,
  difficult to evacuate
• Straining? anal block? self-digitate?
• Recent change obstructive ?Ca
• Medication
• Opiates, antidepressants (TCAs), iron,
  aluminium/calcium antacids
• Endocrine
• Hypothyroidism, diabetes,
• Pain
• Fissure-in-ano, post-op, haemorrhoids
• Lifestyle
• Neglect impulse to defecate accumulate hard
  stool, constant rectal distension thus lose
  awareness
• Neuroligical
• Disorder of pelvic floor muscle, hirschsprungs,
  autonomic neuropathy, spinal cord injury,
  multiple sclerosis
• Slow transit

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Other symptoms

• Abdominal bloating/swelling
• Excess gas
• IBS
• Persistent Ascites
• Lethargy
• Acute/chronic liver disease
• Anaemia Ca, IBD, chronic GI disease

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Complete History by

• PMH
• Previous surgery to GI system
• Previous GI problems
• Transfusions
• Dental treatment
• DH
• medication could be causing symptoms
• SH
• Occupation exposure to toxins (carbon
  tetrachloride, vinyl chloride) causing liver
  disease, health care workers exposed to hepatitis
• Travel Hx
• Drug misuse
• Alcohol Hx
• Tattoos
• FH
• Colon Ca, IBD
• Jaundice, anaemia, splenectomy, cholecystectomy

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Finally...

• Very brief relevant systems review
• End History by
• Summarise and confirm
• Ask pt concerns
• Thank pt
• Summarise findings
• This is a X yr old lady/gent who presented with
  a Y day/week/month Hx of Z. Brief description of
  relevant findings. Based on this assessment my
  differentials are XYZ. Brief plan to
  investigate.
• Investigations
• Routine bloods FBC, UEs, LFTs, CRP, Clotting
• Imaging CXR/AXR, USS abdomen, ERCP/MRCP, CT,
  flexible sigmoidoscopy/colonoscopy, biopsy
• Specific specialised tests Liver screen, Coeliac
  screen, Hameatinics, H.pylori test, Ascitic tap

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Examination

• Wash hands
• Introduction
• Explanation
• Very brief history whats brought you in today?
  Where about is the pain?
• ABC!!
• Just to let examiner know you know!

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Inspection

• At bedside
• well, comfortable, chachectic, sitting
  forward/very still, rolling in bed, drowsy/alert
• obvious pallor or jaundice
• SOB, tremulous
• Obvious abdominal distension
• Stoma
• Surrounding
• Catheter
• Ascitic drain
• Oxygen
• NG tube
• Iv fluids

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Inspection (cont)

• Hands and nails
• Clubbing liver cirrhosis, IBD, Coeliacs, GI
  lymphoma
• Palmer erythema
• Dupuytrens contracture
• Leuchonychia hypoalbuminaemia
• cirrhosis, protein-losing enteropathy
• Koilonychia
• Asterixes/hepatic flap encephalopathy
• Bullae porphyria cutanea tarda
• Alcoholic liver disease

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Inspection (cont.)

• Arms
• Scratch marks
• Obstructive jaundice, lymphoma
• Bruising hepatic impairment
• Muscle wasting
• Alcohol, steroid use, malignancy
• Face
• Jaundice
• Anaemia
• pallor of conjunctiva, glossitis, angular
  stomatitis
• Kayser-Fleischer rings Wilsons disease
• Iritis IBD
• Xanthelasma Primary Biliary Cirrhosis
• Pigmentation of mucosa
• Peutz-Jeghers synd., chronic liver disease,
  Addisons
• Apthous ulcers and lip swelling Chrons

Iritis
Xanthelasma
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Inspection...finally

• Trunk
• Spider naevi
• gt5 in SVC distribution CLD, pregnancy,
  hyperthyroidism
• Gynaecomastia CLD
• Sexual hair loss CLD
• Abdomen
• Scars
• distension fluid, fat, flatus, faeces, fetus,
  fibroids
• Caput medusae
• Bruising
• Cullens and Grey Turners acute pancreatitis
• Obvious peristalsis obstruction/very thin
• Legs
• Pitting oedema

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Palpation

• Ask pt where is pain? (start away from here)
• Follow quadrants/regions
• Watch pts face throughout!
• Masses
• Site
• Tenderness
• Size
• Surface/edge
• Consistency
• Mobility
• Pulsatile?
• Get above or below?
• Guarding/rebound tenderness peritonitis

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Examination of Liver

• Hand parallel to costal margin
• RIF to costal margin
• Feel on inspiration
• Pain/tenderness
• Measure size
• Finger breadths from costal margin
• Liver span
• Percussion
• Auscultate
• Liver hum HCC

• Hepatomegaly
• Metastasis
• HCC
• Myeloproliferative
• RHF
• ALD
• Haematological disease
• Hepatitis
• Fatty liver

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Examining Ascites

• From centre to flanks
• Flanks will become dull, as fluid settled
• Fluid thrill
• Shifting dullness
• Percuss to right flank of patient dull
• Ask pt to turn onto left side wait
• Re-percuss to right flank resonant

• Classifying Ascites
• Exudate (gt30g protein/L)
• Carcinomatous infiltration
• Acute pancreatits
• Infection
• Transudate (lt30g protein/L)
• Portal hypertension
• CCF
• Nephrotic syndrome
• Ovarian tumour

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Examination of gallbladder

• Below right costal marging, lateral border of
  rectus abdominis
• Bulbous, focal, round mass, moves with
  inspiration
• Murphys sign cholecystitis
• Painful palpation of right costal margin on
  inspiration
• Courvoisiers law
• Enlarged gallbladder and pt jaundiced, unlikely
  gallstones (gallbladder fibrosed)

• Gallbladder enlargement
• with jaundice
• Ca pancreas
• Ca ampulla of Vater
• without jaundice
• Ca gallbladder
• Acute cholecystitis
• Mucocele/ empyema

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Examination of spleen

• 2 hands
• Posterolateral left lower ribs
• Palpate with right, start RIF
• Features of spleen
• Moves with early in inspiration
• Cant get above
• Notched edge
• Dull to percuss
• Enlarge towards umbilicus

• Splenomegaly
• Chronic liver disease Portal hypertension
• Infection viral hep, cmv, infectious
  mononucleosis
• Haematological disease

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Other findings

• Tender epigastrium PUD
• Succussion splash gastric outlet obstruction
• RIF pain, peritonism appendicitis
• Pancreatic pseudocyst
• Aortic aneurysm expansile pulsation
• Virchows node Gastric Ca

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Finally...

• Percussion
• Auscultation
• Bowel sounds
• normal/sluggish/tinkling/borborygmi/absence
• Friction rubs
• Inflammation
• Venous hums
• Portal hypertension
• Bruit
• Chronic mesenteric ischaemia mesenteric artery
  stenosis
• To complete examination
• Hernias
• PR
• Urinalysis
• Present positive findings and give differential
  diagnosis
• To investigate this further I would...(as
  previous)
• Routine blood/imaging/specific tests

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Common OSCE stations

• Spotters
• Stoma (later slide)
• Abdominal scars
• Laparotomy, appendicectomy, cholecystectomy
• Remember laparoscopic possibilities
• Jaundice Liver cirrhosis, Hepatitis
• Ascites
• Ascitic drain
• Clubbing IBD, Liver cirrhosis

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History stations

• IBD
• Peptic ulcer disease
• Oesophagitis
• Gallstones
• Cholecystitis
• Pancreatitis
• Hepatitis
• Colorectal cancer

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Acute abdomen

• Always SP for this station
• Remember ABC!!
• Focussed history
• SOCRATES
• Focussed abdominal examination
• Present only positives!
• Summarise
• Differential Diagnosis
• Investigations

• Common scenarios
• Appendicitis
• Cholecystitis
• Pancreatitis

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Stomas

• An artificial opening in abdominal wall
• Passage of waste faeces/urine
• Non-functioning/Mucous fistula
• Temporary/Permanent
• Single opening (A) or double barrelled (B)
  (emergency)
• Why formed
• IBD
• Cancer
• Trauma
• Severe diverticular disease
• Types
• Colostomy flush with skin, solid contents
• Ileostomy spouted, porridge-like contents
• Jejunostomy
• Gastrostomy
• Urostomy (with ileal conduit)

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Stomas

• Complications
• Early
• Haemorrhage at site
• Ischaemia
• High output electrolyte losses
• Obstruction adhesions
• Retraction
• Delayed
• Dermatitis
• Prolapse
• Parastomal hernia
• Fistulae
• Psychological smell, relationship problems
• Stoma Nurse Specialists!!!

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Explanation stations

• Explain chronic condition and/or management
• Iron deficiency anaemia starting iron
• IBD
• Peptic ulcer disease Triple therapy
• Explain procedures
• Colonoscopy
• OGD
• Biopsy
• Breaking bad news
• Not always cancer!
• Chronic disease
• Explain to relative

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Interpretation

• Liver function tests
• Anaemia
• Iron deficiency
• Pernicious anaemia
• Macrocytic
• Hepatitis screens
• Viral screen A, B, C
• HBsAg ve 1-6 months (gt6 monthscarrier status)
• HBeAg ve 1-3 monthshigh infectivity
• Anti-HBc ve past infection
• Anti-HBs ve alone vaccination