Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

PART 2 OSCE SERIES THE GASTROENETEROLOGY STATION ALAA CATTAEH PROUDLY IN COLLABORATION WITH Role FY1 Setting Emergency department Patient Tami Payne, a 32-year-old female presents with abdominal pain STUDENT Student Perform a focused gastrointestinal examination on this patient task your findings and present a differential diagnosis.o summarise INSTRUCTIONSTHE BASICS Tips For All Physical Examinations LOOK 01 03 WIPE 05 BE SYSTEMATIC For general inspection, LOOK at thes perform WIPE BE SYSTEMATIC and try to look slick patient and around the bed for a good few moments WORDING RIGHT SIDE SHOWTIME! 02 04 06 When talking in between the sideine from the patient’s rightUT ON A SHOW! examination, say ‘’there is no looking for …’’ rather than ‘’I am Preamble 1. Perform WIPE 2. Introduction: “’Hello, my name is …. and I am a medical student. Can I confirm your full name and age please? Today , I’ve been asked to perform an examination of your abdomen. What that will involve is me having a general look of you, examining your hands, face, neck, abdomen and legs. I will also have a feel and listen to your abdomen. Does that sound okay? Do I have your consent? Just to let you know , I will also be talking out loud to the examiner while I perform the examination to let him/her know what I am looking for. Are you in any pain at the moment? Where is the pain? The examination should not be painful but if you feel any discomfort, please let me know.” SPOT DIAGNOSIS On examination, the patient has spider naevi on his chest and gynecomastia. Deep palpation of the RUQ revealed a CIRRHOSIS nodular liver edge and splenomegaly. The patient presents with fever and confusion. On examination, there is generalised abdominal tenderness, SPONTANIOUS BACTERIAL PERITONITIS moderate abdominal distension, and shifting dullness. On examination, the patient has generalised abdominal tenderness. There is evidence of aphthous ulceration CROHN’S DISEASE inside her mouth and erythema nodosum on her shins. The patient presents with sudden severe abdominal cramps. On examination, he has a soft and non-distended ACUTE MESENTERIC ISCHAEMIA abdomen which is very tender on palpation throughout. ABG revealed acidosis with raised lactate.THE ABDOMINAL EXAMINA TION GENERAL INSPECTION MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA BEDSIDE: BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ VOMIT BOWL PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ OBVIOUS SCARS/ ABDOMINAL DISTENTION/ CACHEXIA INSPECT GENERAL INSPECTION Vomit bowl Feeding tube Ascitic drain Surgical drain Stoma bag Parenteral nutrition BEDSIDE INSPECT GENERAL INSPECTION Cachexia Abdominal distention Comfortable at rest? Jaundice Pallor Pedal oedema Scars Hyperpigmentation/ PATIENT bronzing of skin INSPECT ABDOMINAL INCISIONS Kocher/ Subcostal Incision Mercedes-Benz Incision Midline Laparotomy Incision Paramedian Laparotomy Incision Gridiron/ McBurney’s Incision Rutherford-Morrison Incision Lanz Incision Pfannenstiel Incision THE EXAMINA TION Face Neck Chest Arms Abdomen Hands Legs GENERAL INSPECTION HANDS & ARMS INSPECTION: PALMAR ERYTHEMA BEDSIDE: MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA KOILONYCHIA BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ LEUKONYCHIA VOMIT BOWL FINGER CLUBBING BRUISING NEEDLE TRACK MARKS TATTOOS PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ FINGERPRICK MARKS OBVIOUS SCARS/ ABDOMINAL DISTENTION/ CHECK FOR DUPUYTREN’S CONTRACTURE CACHEXIA CHECK RADIAL PULSE CHECK FOR FINE TREMOR CHECK FOR FLAPPING TREMOR (ASTERIXIS) OFFER TO CHECK BLOOD PRESSURE IN BOTH ARMSINSPECT HANDS & ARMS FINGER/NAIL SIGNS Leukonychia Koilonychia Clubbing Hypoalbuminemia Iron deficiency anaemia GI Causes End-stage liver disease, protein-losing enteropathy Malabsorption IBD Lymphoma CirrhosisINSPECT HANDS & ARMS PALMS Palmar erythema Dupuytren’s contracture Risk factors Xanthoma Pallor Genetics Age Alcohol Male DiabetesINSPECT HANDS & ARMS ARMS Track marking Arteriovenous fistula Excoriations BruisingINSPECT HANDS & ARMS ASTERIXIS *Video Underlying Causes Uraemia Hepatic CO2 retention encephalopathy 1. Ask the patient to stretch their arms out in front Renal failure Increased Type 2 resp of them failure 2. Then ask them to cock their writs back and hold ammonia position for 30 seconds 3. Observe for evidence of asterixisPALPATE HANDS & ARMS TEMPERATURE & RADIAL PULSE Assess temperature by placing dorsal he dorsal aspect of your ▪ Palpate radial pulse with 2 , 3 & hand onto the patient’s 4 fingers ▪ Comment on rate, rhythm, volume ❖ Offer to measure blood pressure in both arms GENERAL INSPECTION HANDS & ARMS FACE & NECK INSPECTION: PALMAR ERYTHEMA INSPECT EYES: CONJUNCTIVAL PALLOR BEDSIDE: MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA KOILONYCHIA SCLERAL ICTERUS BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ LEUKONYCHIA CORNEAL ARCUS VOMIT BOWL FINGER CLUBBING XANTHELASMA BRUISING KAYSER-FLEISCHER RINGS NEEDLE TRACK MARKS INSPECT FACE & MOUTH: ANGULAR STOMATITIS TATTOOS GLOSITIS PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ FINGERPRICK MARKS APHTHOUS ULCERATION OBVIOUS SCARS/ ABDOMINAL DISTENTION/ CHECK FOR DUPUYTREN’S CONTRACTURE DENTAL HYGIENE CACHEXIA CHECK RADIAL PULSE CHECK FOR FINE TREMOR ORAL CANDIDIASIS CHECK FOR FLAPPING TREMOR (ASTERIXIS) EXAMINE JVP OFFER TO CHECK BLOOD PRESSURE IN BOTH ARMS PALPATE FOR LYMPHADENOPATHYINSPECT F ACE & NECK EYES Conjunctival pallor Kayser-Fleicher ring Anterior uveitis Corneal arcus Icterus XanthelasmaINSPECT F ACE & NECK MOUTH Angular stomatitis Aphthous ulceration Glossitis Oral candidiasis Hyperpigmented macules Data Interpretation A 35-year-old male presents to the gastroenterology clinic A Crohn’s disease with a history of chronic abdominal pain, diarrhoea and weight loss. On physical examination, the patient is noted to be pale, with perilimbal injection seen in his eyes and B Ulcerative colitis aphthous ulceration inside his mouth. His abdomen is tender to palpation in the RLQ. A colonoscopy is performed, which shows the following: C Coeliac disease D Irritable bowel syndrome E Colorectal cancer What is the most likely diagnosis? Data Interpretation A 35-year-old male presents to the gastroenterology clinic A Crohn’s disease with a history of chronic abdominal pain, diarrhoea and weight loss. On physical examination, the patient is noted to be pale, with perilimbal injection seen in his eyes and B Ulcerative colitis aphthous ulceration inside his mouth. His abdomen is tender to palpation in the RLQ. A colonoscopy is performed, which shows the following: C Coeliac disease D Irritable bowel syndrome E Colorectal cancer What is the main feature shown in this What is the most likely diagnosis? image which supports your diagnosis?PALPATE F ACE & NECK NECK *Video Palpate lymph nodes Examine JVP Enlargement can be a sign of intrabdominal malignancy Virchow’s node GENERAL INSPECTION HANDS & ARMS FACE & NECK INSPECTION: PALMAR ERYTHEMA INSPECT EYES: CONJUNCTIVAL PALLOR BEDSIDE: MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA KOILONYCHIA SCLERAL ICTERUS BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ LEUKONYCHIA CORNEAL ARCUS VOMIT BOWL FINGER CLUBBING XANTHELASMA BRUISING KAYSER-FLEISCHER RINGS NEEDLE TRACK MARKS TATTOOS INSPECT FACE & MOUTH: ANGULAR STOMATITIS PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ FINGERPRICK MARKS GLOSITIS OBVIOUS SCARS/ ABDOMINAL DISTENTION/ APHTHOUS ULCERATION CACHEXIA CHECK FOR DUPUYTREN’S CONTRACTURE DENTAL HYGIENE CHECK RADIAL PULSE ORAL CANDIDIASIS CHECK FOR FINE TREMOR EXAMINE JVP CHECK FOR FLAPPING TREMOR (ASTERIXIS) OFFER TO CHECK BLOOD PRESSURE IN BOTH ARMS PALPATE FOR LYMPHADENOPATHY CHEST INSPECTION: SPIDER NAEVI GYNAECOMASTIA HAIR LOSSINSPECT CHEST Spider naevi Gynaecomastia Caused by increased oestrogen Liver cirrhosis ❖ Check for hair loss in Acanthosis nigricans chest and axilla LET’S HAVE A BREAK! PLEASE TUNE IN TO THE REST OF OUR OSCE SERIES SPOT DIAGNOSIS On examination, the patient has tenderness with guarding in the RUQ. She also has a fever. Deep palpation of the ACUTE CHOLECYSTITIS RUQ causes respiratory arrest (Murphey’s sign positive). The patient presents with fever and jaundice. On examination, there is scleral icterus and RUQ tenderness. ACUTE CHOLANGITIS The patient presents with sudden-onset epigastric pain that radiates to the back. On examination, the upper ACUTE PANCREATITIS abdomen is tender with voluntary guarding. The patient presents with abdominal pain and low-grade fever. On examination there is tenderness on the LLQ. DIVERTICULITIS GENERAL INSPECTION HANDS & ARMS FACE & NECK INSPECTION: PALMAR ERYTHEMA INSPECT EYES: CONJUNCTIVAL PALLOR BEDSIDE: MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA KOILONYCHIA SCLERAL ICTERUS BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ LEUKONYCHIA CORNEAL ARCUS VOMIT BOWL FINGER CLUBBING XANTHELASMA BRUISING KAYSER-FLEISCHER RINGS NEEDLE TRACK MARKS INSPECT FACE & MOUTH: ANGULAR STOMATITIS TATTOOS GLOSITIS PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ FINGERPRICK MARKS APHTHOUS ULCERATION OBVIOUS SCARS/ ABDOMINAL DISTENTION/ CHECK FOR DUPUYTREN’S CONTRACTURE DENTAL HYGIENE CACHEXIA CHECK RADIAL PULSE CHECK FOR FINE TREMOR ORAL CANDIDIASIS CHECK FOR FLAPPING TREMOR (ASTERIXIS) EXAMINE JVP OFFER TO CHECK BLOOD PRESSURE IN BOTH ARMS PALPATE FOR LYMPHADENOPATHY CHEST ABDOMEN INSPECTION: SCARS INSPECTION: SPIDER NAEVI ABDOMINAL DISTENTION GYNAECOMASTIA CAPUT MEDUSAE HAIR LOSS STRIAE HERNIAS STOMAS PALPATION: LIGHT & DEEP PALPATION OF THE 9 REGIONS LIVER & GALLBLADDER SPLEEN PERCUSSION: LIVER AUSCULTATE: BOWEL SOUNDS KIDNEYS SPLEEN BRUITS AORTA BLADDER BLADDER ASSESS SHIFTING DULLNESSINSPECT ABDOMEN Scars/ abdominal incisions Abdominal distention Causes (6Fs) Caput medusae Fat Fluid Faeces Flatus Foetus Fulminant mass Portal hypertension (e.g. liver cirrhosis)INSPECT ABDOMEN Striae Grey-Turner’s sign Cullen’s sign Late signs associated with haemorrhagic pancreatitis HerniasINSPECT ABDOMEN STOMA ASSESSMENT Right iliac fossa – ileostomy Location Left iliac fossa – colostomy Stool – ileostomy/ colostomy Contents Urine – urostomy Liquid – ileostomy Consistency Solid – colostomy Present – ileostomy/ urostomy Spout Absent – colostomy PALPATE ABDOMEN PALPATION OF THE 9 ABDOMINAL REGIONS ❖ Always palpate away from painful areas first Light Palpation • - Lightly palpate all 9 regions. The patient should positioned lying • - Look at the patient’s face flat on the bed. • - Assess for tenderness, guarding, superficial masses (e.g. hernias) Right Left hypochondriacEpigastrihypochondriac Deep Palpation Umbilical • - Apply more pressure/ use 2 hands Right Left lumbar lumbar • - Warn patient this may feel uncomfortable, monitor their face • - Try identify any deeper masses and assess location, size, RightHypogastriLeft consistency, pulsitality inguinal inguinal PALPATE ABDOMEN LIVER 1. Ask patient to breathe in & out 2. Palpate in during inspiration The patient should 3. Start in the RLQ and move up positioned lying flat on the bed. PALPATE ABDOMEN LIVER BORDER Once you identify the liver edge assess the following: ▪ Degree of extension: >2cm below costal margin = hepatomegaly ▪ Consistency: nodular = cirrhosis The patient should ▪ Tenderness: hepatitis or cholecystitis already be flat on the bed. ▪ Pulstality: pulsatile hepatomegaly = tricuspid regurgitation MASSIVE HEPATOMEGALLY CRAM Cancer, RH, Alcoholic liver disease, Myeloproliferative disease (CML, Ruba Vera) CAUSES OF MODERATE HEPATOMEGALLY All above + FAILL HEP A TOMEGALY Fatty liver, Amyloidosis, Iron (haemochromatosis), Lymphoma, Leukemia MILD HEPATOMEGALLY All above + Biliary duct obstruction, infection (hep, EBV,, HIV CMV), autoimmune, tricuspid regurgitation Data Interpretation A 65-year-old patient presented to the clinic with complaints A Cholecystitis of yellowing of his skin. Upon physical examination, the patient was found to have jaundice with yellowing of the skin and sclera. Abdominal examination revealed a distended B Pancreatic cancer gallbladder on deep palpation, but no tenderness was noted. His laboratory investigations show the following: C Gilbert’s syndrome Liver Function Tests Result Normal Range ALT 60 iu/L 3-40 iu/L AST 25 iu/L 3-30 iu/L D Hepatocellular carcinoma ALP 400 umol/L 30-100 umol/L GGT 200 u/L 8-60 u/L Total bilirubin 90 µmol/L 3-17 µmol/L E Gallstones in bile duct Biomarkers Result Normal Range CA 19-9 150 kU/L <37 kU/L CEA 5 μg/L <3 μg/L What is this patient’s most likely diagnosis? Data Interpretation A 65-year-old patient presented to the clinic with complaints A Cholecystitis of yellowing of his skin. Upon physical examination, the patient was found to have jaundice with yellowing of the skin and sclera. Abdominal examination revealed a distended B Pancreatic cancer gallbladder on deep palpation, but no tenderness was noted. His laboratory investigations show the following: C Gilbert’s syndrome Liver Function Tests Result Normal Range ALT 60 iu/L 3-40 iu/L AST 25 iu/L 3-30 iu/L D Hepatocellular carcinoma ALP 400 umol/L 30-100 umol/L GGT 200 u/L 8-60 u/L Total bilirubin 90 µmol/L 3-17 µmol/L E Gallstones in bile duct Biomarkers Result Normal Range CA 19-9 150 kU/L <37 kU/L ▪ Painless obstructive jaundice is a key presenting CEA 5 μg/L <3 μg/L feature of pancreatic cancer. ▪ LFTs show cholestatic pattern What is this patient’s most likely diagnosis? ▪ CA 19-9 and CEA are tumour markers that may be associated with pancreatic cancer ▪ CA-19-9 has 80% sensitivity and 90% specificity PALPATE ABDOMEN GALLBLADDER ▪ Not usually palpable ▪ If palpable = enlargement due to biliary obstruction The patient should already be flat on the bed. Murphey’s Sign 1. Place your fingers at the right costal margin, mid-clavicular line at the liver’s edge 2. Ask the patient to take a deep breath in Patient suddenly stops mid-breath due to pain → “Murphy’s sign positive” = cholecystitis Tenderness suggests a diagnosis of cholecystitis whereas a distended painless gallbladder may indicate underlying pancreatic cancer (particularly if also associated with jaundice). PALPATE ABDOMEN SPLEEN 1. Ask patient to breathe in & out 2. Palpate in during inspiration The patient should 3. Start in the RLQ and move up & into LUQ positioned lying flat on the bed. Portal hypertension secondary to liver cirrhosis Haemolytic anaemia CAUSES OF SPLENOMEGALY Congestive heart failure Splenic metastases Glandular fever C CML / CLL H Hairy cell leukemia CAUSES OF MASSIVE SPLENOMEGALY I Infections e.g. malaria M Myelofibrosis P Polycythaemia vera PALPATE ABDOMEN KIDNEYS 1. Place left hand behind the patient’s back 2. Then place right hand on anterior abdominal wall, below right costal margin 3. Push upwards with left hand, and downwards with right hand The patient should positioned lying and ask patient to take deep breath in flat on the bed. 4. If the kidney is ballotable, describe its size and consistency. 5. Repeat process on opposite side Right kidney Left kidney PALPATE ABDOMEN AORTA ▪ Use both hands to perform deep palpation superior to the umbilicus, midline ▪ Your hands should move superiorly with The patient should positioned lying each pulsation of the aorta flat on the bed. ▪ If your hands move outwards → presence of expansile mass (e.g. AAA) Press down with fingertips PERCUSS ABDOMEN PERCUSSION OF THE ABDOMEN ▪ Percuss the 9 regions of the abdomen The patient should ▪ Assess for shifting dullness if suspecting ascites positioned lying flat on the bed. Right Epigastric Left hypochondriac hypochondriac Umbilical Right Left lumbar lumbar Right Hypogastric Left inguinal inguinal PERCUSS ABDOMEN LIVER ▪ Percuss from RLQ towards the right costal margin ▪ Note the location when the percussion note changes from resonant to dull = lower liver border The patient should already be ▪ Continue to percuss upwards until percussion note flat on the bed. changes from dull to resonant = upper liver border PERCUSS ABDOMEN SPLEEN ▪ Percuss from RLQ towards the left costal margin until the percussion note changes from resonant to dull indicating the location of the spleen The patient should already be ▪ Normally, the spleen is not identifiable on percussion flat on the bed. (unless patient has splenomegaly) PERCUSS ABDOMEN BLADDER ▪ Percuss down from umbilical region towards the The patient should pubic symphysis to assess distended bladder positioned lying flat on the bed. ▪ Ask the patient if they need to go to the toilet first! AUSCULTATE ABDOMEN BOWEL SOUNDS Assess bowel sounds The patient should ▪ Normal bowel sounds: gurgling positioned lying ▪ Tinkling bowel sounds: may indicate bowel obstruction flat on the bed. ▪ Absent bowel sounds: may indicate ileus *Audio AUSCULTATE ABDOMEN BRUITS ▪ Aorta: use diaphragm and auscultate above umbilicus ▪ Aortic bruit = AAA The patient should ▪ Renal arteries: use the bell and auscultate above & already be flat on the bed. lateral to umbilicus ▪ Renal bruit = renal artery stenosis * Audio GENERAL INSPECTION HANDS & ARMS FACE & NECK INSPECTION: PALMAR ERYTHEMA INSPECT EYES: CONJUNCTIVAL PALLOR BEDSIDE: MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA KOILONYCHIA SCLERAL ICTERUS BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ LEUKONYCHIA CORNEAL ARCUS VOMIT BOWL FINGER CLUBBING XANTHELASMA BRUISING KAYSER-FLEISCHER RINGS NEEDLE TRACK MARKS TATTOOS INSPECT FACE & MOUTH: ANGULAR STOMATITIS PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ FINGERPRICK MARKS GLOSITIS OBVIOUS SCARS/ ABDOMINAL DISTENTION/ APHTHOUS ULCERATION CACHEXIA CHECK FOR DUPUYTREN’S CONTRACTURE DENTAL HYGIENE CHECK RADIAL PULSE ORAL CANDIDIASIS CHECK FOR FINE TREMOR EXAMINE JVP CHECK FOR FLAPPING TREMOR (ASTERIXIS) OFFER TO CHECK BLOOD PRESSURE IN BOTH ARMS PALPATE FOR LYMPHADENOPATHY LEGS ABDOMEN CHEST INSPECTION: SPIDER NAEVI CHECK FOR: PITTING OEDEMA INSPECTION: SCARS ERYTHEMA NODOSUM ABDOMINAL DISTENTION GYNAECOMASTIA PYODERMA GANGRENOSUM CAPUT MEDUSAE HAIR LOSS STRIAE HERNIAS STOMAS PALPATION: LIGHT & DEEP PALPATION OF THE 9 REGIONS LIVER & GALLBLADDER SPLEEN PERCUSSION: LIVER AUSCULTATE: BOWEL SOUNDS KIDNEYS SPLEEN BRUITS AORTA BLADDER BLADDER ASSESS SHIFTING DULLNESSINSPECT LEGS Pitting oedema Erythema nodosum Causes: NODOSUM NO NO cause S Sarcoidosis (idiopathic) (Lofgren’s syndrome) Drugs D (e.g. sulphonamides) U UC & Crohn’s Pyoderma gangrenosum O Oral contraceptives M Microbes GENERAL INSPECTION HANDS & ARMS FACE & NECK INSPECTION: PALMAR ERYTHEMA INSPECT EYES: CONJUNCTIVAL PALLOR BEDSIDE: MEDICATIONS/ OXYGEN/ FEEDING TUBE/ STOMA KOILONYCHIA SCLERAL ICTERUS BAG/ MOBILITY AIDS/ SURGICAL DRAINS/ CATHETER/ LEUKONYCHIA CORNEAL ARCUS VOMIT BOWL FINGER CLUBBING XANTHELASMA BRUISING KAYSER-FLEISCHER RINGS NEEDLE TRACK MARKS TATTOOS INSPECT FACE & MOUTH: ANGULAR STOMATITIS PATIENT: COMFORTABLE AT REST/ JAUNDICE/ OBESITY/ FINGERPRICK MARKS GLOSITIS OBVIOUS SCARS/ ABDOMINAL DISTENTION/ APHTHOUS ULCERATION CACHEXIA CHECK FOR DUPUYTREN’S CONTRACTURE DENTAL HYGIENE CHECK RADIAL PULSE ORAL CANDIDIASIS CHECK FOR FINE TREMOR EXAMINE JVP CHECK FOR FLAPPING TREMOR (ASTERIXIS) OFFER TO CHECK BLOOD PRESSURE IN BOTH ARMS PALPATE FOR LYMPHADENOPATHY LEGS ABDOMEN CHEST INSPECTION: SPIDER NAEVI CHECK FOR: PITTING OEDEMA INSPECTION: SCARS ERYTHEMA NODOSUM ABDOMINAL DISTENTION GYNAECOMASTIA PYODERMA GANGRENOSUM CAPUT MEDUSAE HAIR LOSS STRIAE HERNIAS STOMAS PALPATION: LIGHT & DEEP PALPATION OF THE 9 REGIONS LIVER & GALLBLADDER SPLEEN PERCUSSION: LIVER AUSCULTATE: BOWEL SOUNDS KIDNEYS SPLEEN BRUITS AORTA BLADDER THANK THE PATIENT AND RESTORE CLOTHING BLADDER ASSESS SHIFTING DULLNESS PRESENT YOUR FINDINGS ▪ Today I performed a gastrointestinal examination on, ____, a ___ year old male /female with ____ ▪ On general inspection, the patient appeared comfortable at rest ▪ Around the bed, there were no signs of any peripheral stigmata of gastrointestinal disease such as surgical drains ▪ On examination of the hands, arms and face, there was no evidence of gastrointestinal abnormalities ▪ The pulse was __, regular and had a strong volume. ▪ JVP was not elevated ▪ Examination of the neck did not reveal evidence of lymphadenopathy ▪ On closer inspection of the abdomen, there were no evidence of abdominal distension or surgical scars ▪ On palpation, the abdomen was soft and non-tender and there was no evidence of organomegaly ▪ Percussion note was resonant on all regions of the abdomen ▪ On auscultation, bowel sounds were present and normal ▪ In summary, these findings are consistent with a normal gastrointestinal examination. ▪ To complete my examination, I would like to perform a Digital rectal examination. I would take a formal history and a full set of Observations. I would like to also perform Urinalysis. I would also consider examining external Genitalia if appropriate and the Hernial orifices. DOUGH LET’S HAVE A BREAK! PLEASE TUNE IN TO THE REST OF OUR OSCE SERIESCASES Role FY1 Setting Emergency department Patient Tami Payne, a 32-year-old female presents with abdominal pain STUDENT Student Perform a focused gastrointestinal examination on this patient task your findings and present a differential diagnosis.o summarise INSTRUCTIONS McBurney’s point tenderness on light palpation Reduced bowel sounds On examination… Guardinon palpation of the RLQ pain in the RLQlicits What are your differentials? Answer in chat! ABDOMINAL P AIN LOCA TION RUQ Epigastric RLQ LLQ ▪ Gallstones ▪ Gastritis ▪ Appendicitis ▪ Diverticulitis ▪ Cholecystitis ▪ Peptic ulcer disease ▪ IBD (UC & Crohn’s) ▪ Colitis ▪ Cholangitis ▪ Pancreatitis (may also be ▪ Bowel obstruction ▪ Large bowel obstruction ▪ Biliary dyskinesia periumbilical or LUQ pain) ▪ Pelvic inflammatory ▪ Renal colic ▪ Biliary obstruction ▪ Cholecystitis disease (PID) ▪ Pelvic inflammatory ▪ Primary sclerosing ▪ Biliary colic ▪ Ovarian cyst or torsion disease (PID) cholangitis ▪ Bowel obstruction ▪ Ectopic pregnancy ▪ Ovarian cyst or torsion ▪ Hepatitis ▪ Gastroparesis ▪ Diverticulitis ▪ Ectopic pregnancy ▪ Cirrhosis ▪ Duodenal ulcer ▪ Inguinal hernia ▪ Endometriosis ▪ Hepatic congestion (HF) ▪ IBD (UC & Crohn’s) ▪ NAFLD ▪ Mesenteric ischaemia APPENDICITIS INITIAL PRESENTATION SIGNS & SYMPTOMS Typically presents as acute abdominal pain ▪ Loss of appetite (anorexia) ▪ Nausea and vomiting starting in the periumbilical region and ▪ Low-grade fever later localising to the right lower quadrant. ▪ Rovsing’s sign (palpating LLQ → RLQ pain) ▪ Guarding & rebound tenderness in the RLQ ▪ Reduced bowel sounds (sign of perforated appendicitis) INVESTIGATIONS MANAGEMENT ▪ CONSERVATIVE: active observation & ▪ BEDSIDE: Urinalysis, pregnancy test supportive treatment (IV fluids, ▪ BLOODS: FBC (leukocytosis), U&E, CRP analgesia, antibiotics, nil-by-mouth etc.) ▪ IMAGING: abdominal ultrasound, ▪ SURGICAL: laparoscopic appendicectomy contrast-enhanced abdominal CT is the definitive treatment ACUTE CHOLECYSTITIS ▪ Inflammation of the gall bladder (complication of gallstones) ▪ RUQ pain + fever ▪ Tachycardia & tachypnoea ▪ Murphey's sign ▪ Rasted inflammatory markers & WBCs ▪ 1 investigation to order: abdominal USS ▪ Management: ▪ Inflammation of the bile ducts (bacterial infection) - Efluids, antibiotics etc.gesia, IV VS ▪ RUQ pain + fever + jaundice (Charcot's triad) - Early laparoscopic ▪ FBCs: ↑WCC cholecystectomy ▪ LFTs: cholestatic pattern (↑↑↑AL, ↑ALT, ↑AST) ▪ Management: - Emergency admission, IV fluids, blood cultures, antibiotics, intensive medical management - ERCP for biliary tree decompression ACUTE CHOLANGITIS A CUTE P ANCREA TITIS INITIAL PRESENTATION SYMPTOMS Severe sudden-onset mid-epigastric or ▪ Severe epigastric pain left upper quadrant abdominal pain, ▪ Radiating through to the back which often radiates to the back. ▪ Abdominal tendernessvomiting The most common causes are gallstones ▪ Systemically unwell (e.g. low-grade and excessive alcohol consumption. fever and tachycardia) INVESTIGATIONS MANAGEMENT ▪ BEDSIDE: ECG, urinalysis ▪ IMMEDIATE: initial resuscitation ▪ BLOODS: serum lipase or amylase, FBC, (ABCDE), IV fluids, analgesia etc. CRP , U&E, LFTs ▪ NON-SURGICAL: ERCP to relieve biliary ▪ IMAGING: contrast-enhanced abdominal obstruction CT, endoscopic ultrasound, MRCP ▪ SURGICAL: cholecystectomy in gallstone pancreatitis INFLAMMA TOR Y BOWEL DISEASE DEFINITION SYMPTOMS Ulcerative colitis (UC) is characterised by ▪ UC: rectal bleeding, chronic diarrhoea, diffuse inflammation of the colonic mucosa lower abdominal pain, faecal urgency, and a relapsing, remitting course. and extraintestinal manifestations Crohn's disease (CD) is characterised by ▪ CD: chronic diarrhoea, weight loss, and transmural inflammation of the GI tract. right lower quadrant abdominal pain INVESTIGATIONS MANAGEMENT ▪ INDUCING REMISSION ▪ BLOODS: FBC, CRP , LFT, iron studies, - UC: aminosalicylate (e.g. mesalazine) - CD: steroids (e.g. oral prednisolone) serum B12, folate ▪ MAINTAINING REMISSION ▪ STOOL tests: faecal calprotectin, culture - UC: mesalazine, azathioprine, mercaptopurine ▪ IMAGING: endoscopy, colonoscopy, - CD: azathioprine, mercaptopurine ultrasound, CT scan, MRI ▪ SURGERY UC: protocolectomy CD: ileocecectomy ULCERATIVE COLITIS UC CLOSE UP C Continuous inflammation L Limited to colon & rectum O Only superficial mucosa affected S Smoking is protective Crow’s E Excrete blood & mucus N o blood or mucus VS U Use aminosalicylates E ntire GI tract P PSC S kip lesions on endoscopy T ransmural inflammation, erminal ileum S moking is a risk factor CROHN’S DISEASE DIVERTICULITIS INITIAL PRESENTATION SYMPTOMS Diverticular disease may be asymptomatic ▪ Pain and tenderness in the LLQ or present with non-specific abdominal ▪ Fever symptoms, such as pain or tenderness. ▪ Diarrhoea ▪ Nausea and vomiting Symptomatic acute diverticulitis presents ▪ Rectal bleeding with fever and left lower quadrant pain. ▪ Palpable abdominal mass (if abscess) INVESTIGATIONS MANAGEMENT ▪ CONSERVATIVE: bowel rest, only taking ▪ BEDSIDE: baseline vital signs, urinalysis clear liquids until symptoms improve, ▪ BLOODS: FBC, U&E, CRP low-residue diet ▪ IMAGING: contrast-enhanced abdominal ▪ MEDICAL: antibiotics (co-amoxiclav), CT, abdominal ultrasound analgesia (avoid NSAIDs) ▪ SURGICAL: open or laparoscopic resection in recurrent diverticulitis Role FY1 Setting Gastrointestinal Ward Patient John Díaz, a 28-year-old male presents with jaundice STUDENT Student Perform a focused gastrointestinal examination on this patient task your findings and present a differential diagnosis.o summarise INSTRUCTIONS Scleral icterus RUQ tenderness on palpation On examination… Palpable liver edge, >2cm below the costal margin What are your differentials? Answer in chat! Data Interpretation A 28-year-old patient presents with complaints of A Haemolytic anaemia jaundice, abdominal pain, nausea and vomiting. His laboratory investigations show the following: B Gilbert’s syndrome Liver Function Tests Result Normal Range ALT 2500 iu/L 3-40 iu/L C Viral hepatitis AST 1000 iu/L 3-30 iu/L ALP 132 umol/L 30-100 umol/L Total bilirubin 90 µmol/L 3-17 µmol/L D Cholangiocarcinoma Albumin 34 g/L 35 - 50 g/L PT 18 secs 10-14 secs E Gallstones in bile duct Which of the following is a possible cause of his jaundice? Data Interpretation A 28-year-old patient presents with complaints of A Haemolytic anaemia jaundice, abdominal pain, nausea and vomiting. His laboratory investigations show the following: B Gilbert’s syndrome Liver Function Tests Result Normal Range ALT 2500 iu/L 3-40 iu/L C Viral hepatitis AST 1000 iu/L 3-30 iu/L ALP 132 umol/L 30-100 umol/L Total bilirubin 90 µmol/L 3-17 µmol/L D Cholangiocarcinoma Albumin 34 g/L 35 - 50 g/L PT 18 secs 10-14 secs E Gallstones in bile duct Which of the following is a possible cause of his jaundice? LFTs are deranged with high transaminases and proportionally less of a rise in ALP . This is referred to as a “hepatitic picture”. JAUNDICE Pre-Hepatic Intra-hepatic Obstructive ▪ Haemolytic anaemia ▪ Viral hepatitis (A-E) ▪ Gallstones ▪ G6PD deficiency ▪ Alcohol related liver disease ▪ Primary biliary cholangitis ▪ Sickle cell anaemia ▪ NAFLD ▪ Primary sclerosing cholangitis ▪ Thalassemia ▪ Autoimmune hepatitis ▪ Cholangiocarcinoma ▪ Hereditary spherocytosis ▪ Drug-induced liver injury ▪ Pancreatic cancer ▪ Infections e.g. malaria ▪ Dubin-Johnson syndrome ▪ Drug-induced cholestasis (Co- ▪ Gilbert’s syndrome ▪ Hepatocellular carcinoma (HCC) amoxiclav, flucloxacillin, COCP) ▪ Crigler-Najjar syndrome ▪ Haemochromatosis ▪ Drugs e.g. sulfonamides ▪ Wilson’s disease ▪ Alpha-1 antitrypsin deficiency ▪ Vascular liver disease VIRAL HEP A TITIS ROUTE OF DIAGNOSTIC CHRONIC TRANSMISSION SYMPTOMS TEST MANAGEMENT INFECTION COMPLICATIONS VACCINE HEPATITIS A Faecal-oral Usually asymptomaticIgM Supportive No Cholestatic hepatitiYes Jaundice, fatigue, antibodies (rare) , Autoimmune N&V. hepatitis (rare) Self-limiting. Usually asymptomatic. ▪ Acute HBV – HEPATITIS B Parenteral, Flu-like illness, general supportive. Yes Cirrhosis, Yes vertical, malaise, jaundice, antibodies ▪ Chronic HBV – Hepatocellular sexual N&V, abdominal pain. antiviral therapy carcinoma HEPATITIS C Parenteral Same as Hep B. PCR of viral ▪ Acute HCV – Yes Cirrhosis, No More chronic. symptomatic. RNA ▪ Chronic HCV – Hepatocellular antiviral therapy carcinoma HEPATITIS E Faecal-oral Usually asymptomaticIgM Supportive No Increased risk of No Jaundice, fatigue, antibodies. mortality in pregnant N&V. women, especially in Self-limiting. PCR of viral third trimester. RNA. CIRRHOSIS DEFINITION SIGNS & SYMPTOMS ▪ Jaundice ▪ Caput Medusae Cirrhosis is the pathological end-stage of any chronic liver disease and most commonly ▪ Hepatomegaly ▪ Pruritus results from chronic hepatitis B and C, ▪ Splenomegaly ▪ Asterixis alcohol-related liver disease, and non- ▪ Spider Naevi ▪ Haematemesis ▪ Palmar Erythema ▪ Melaena alcoholic fatty liver disease (NAFLD). ▪ Bruising ▪ Muscle wasting ▪ Ascites ▪ Oedema INVESTIGATIONS MANAGEMENT ▪ BEDSIDE: history & clinical examination ▪ CONSERVATIVE: High protein, low sodium diet, ▪ BLOODS: FBC, LFTs, PT, serum albumin, avoid alcohol. ▪ MEDICAL: treat stable varices with propranolol. U&Es, anti-HCV, HBsAg Spironolactone for ascites. ▪ IMAGING: ultrasound, FibroScan, liver ▪ SURGICAL: Elastic band ligation of varices, biopsy, endoscopy (for oesophageal Transjugular Intra-hepatic Portosystemic Shunt varices), CT and MRI (to scan for HCC) (TIPS), paracentesis, liver transplantation. CHILD-PUGH SCORE FOR CIRRHOSIS SCORE 1 SCORE 2 SCORE 3 BILIRUBIN <34 34-50 >50 ALBUMIN >35 28-35 <28 INR <1.7 1.7-2.3 >2.3 ASCITES Absent Slight Moderate or severe ENCEPAHLOPATHY None Grade 1 to 2 Grade 3 to 4 ❑ Class A: score 5-6 → well-compensated disease ❑ Class B: score 7-9 → significant functional compromise ❑ Class C: score 10-15 → decompensated disease HEP A TOCELLULAR CAR CINOMA DEFINITION SYMPTOMS HCC, also known as hepatoma, is a ▪ Asymptomatic primary cancer arising from hepatocytes in ▪ Weight loss predominantly cirrhotic liver. However, ▪ Abdominal pain some patients may not have cirrhosis ▪ Anorexia before developing HCC, especially patients ▪ Nausea and vomiting with chronic hepatitis B virus. ▪ Jaundice and pruritus INVESTIGATIONS MANAGEMENT ▪ BEDSIDE: history & clinical examination ▪ CONSERVATIVE: avoid alcohol, improve ▪ BLOODS: FBC, U&E, LFTs, coagulation lifestyle habits (diet & exercise) studies, alpha-fetoprotein (HCC marker) ▪ MEDICAL: Atezolizumab plus ▪ IMAGING: transabdominal ultrasound, bevacizumab ,or sorafenib, or lenvatinib CT and MRI for diagnosis & staging ▪ SURGICAL: resection, transplantation, thermal ablation, chemoembolisation. HAEMOL YTIC ANAEMIA DEFINITION SIGNS & SYMPTOMS Haemolytic anaemia is characterised by the ▪ Fatigue premature destruction of red blood cells. ▪ Shortness of breath ▪ Dizziness Anaemia, reticulocytosis, low haptoglobin, ▪ Pallor high lactate dehydrogenase (LDH), and high ▪ Jaundice indirect bilirubin suggest haemolysis. ▪ Splenomegaly INVESTIGATIONS MANAGEMENT ▪ CONSERVATIVE: staying hydrated and ▪ BEDSIDE: urinalysis, clinical examination avoiding strenuous exercise. Supportive ▪ BLOODS: FBC, reticulocyte count, care, oral iron, folic acid supplementation bilirubin, serum LDH, plasma haptoglobin ▪ Blood transfusion ▪ OTHER TESTS: direct Coombs test, ▪ MEDICAL: prednisolone and rituximab in peripheral blood smear autoimmune haemolytic anaemia ▪ SURGICAL: splenectomy GALLSTONE DISEASE DEFINITION SYMPTOMS Gallstones are small stones that form within ▪ Asymptomatic the gallbladder. Most stones are made of ▪ Biliary colic cholesterol. - Severe, colicky epigastric or RUQ pain - Often triggered by (fatty) meals They can lead to complications, such as acute - Lasting between 30 mins and 8 hrs cholecystitis, acute cholangitis and pancreatitis. - May be associated with nausea INVESTIGATIONS MANAGEMENT ▪ CONSERVATIVE: low-fat diet ▪ BEDSIDE: ECG, clinical examination ▪ MEDICAL: analgesia (paracetamol), ▪ BLOODS: FBC, LFTs, serum amylase consider anti-spasmodic (e.g. hyoscine) ▪ IMAGING: abdominal ultrasound, MRCP ▪ SURGICAL: laparoscopic cholecystectomy P ANCREA TIC CANCER DEFINITION SIGNS & SYMPTOMS 'Pancreatic cancer' refers to primary pancreatic ▪ Painless obstructive jaundice ductal adenocarcinoma. The adenocarcinoma ▪ Yellow skin and sclera most commonly occurs in the head of the ▪ Pale stools pancreas. Once a tumour in the head of the ▪ Dark urine pancreas grows large enough it can compress ▪ Generalised itching the bile ducts, resulting in obstructive jaundice. ▪ Non-specific upper abdominal pain ▪ Weight loss and anorexia INVESTIGATIONS MANAGEMENT ▪ CONSERVATIVE: smoking cessation, limit alcohol ▪ BEDSIDE: history & clinical examination consumption ▪ MEDICAL: chemotherapy (FOLFIRINOX: folinic ▪ BLOODS: FBC, U&E, LFTs, CA19-9 acid, fluorouracil, irinotecan, and oxaliplatin) biomarker ▪ SURGICAL: total pancreatectomy, distal ▪ IMAGING: pancreatic protocol CT, pancreatectomy, the modified Whipple procedure abdominal ultrasound, MRCP (pylorus-preserving pancreaticoduodenectomy) Role FY1 Setting Primary care Patient Mr Hart Stoule, a 67-year-old male presents with constipation STUDENT Student Perform a focused gastrointestinal examination on this patient task your findings and present a differential diagnosis.o summarise INSTRUCTIONS Bowel sounds absent Distended abdomen on auscultation On examination… Mild LLQ tenderness on palpation What are your differentials? Answer in chat! Data Interpretation A Toxic megacolon A 67-year-old patient presented with constipation, abdominal pain and distension. You order an abdominal X-Ray which shows the following: B Small bowel obstruction C Ascites D Caecal volvulus E Sigmoid volvulus What is his most likely diagnosis? Data Interpretation A Toxic megacolon A 67-year-old patient presented with constipation, abdominal pain and distension. You order an abdominal X-Ray which shows the following: B Small bowel obstruction C Ascites D Caecal volvulus E Sigmoid volvulus AXR shows the classic “coffee bean” sign of the twisted sigmoid colon What is his most likely diagnosis? BOWEL OBSTRUCTION DEFINITION SIGNS & SYMPTOMS A bowel obstruction refers to when the passage of food, fluids and gas, through the intestines becomes ▪ Abdominal pain – colicky or cramping in nature (secondary to the bowel peristalsis) blocked. Once the bowel segment has become ▪ Vomiting – occurring early in proximal occluded, gross dilatation of the proximal limb of the obstruction and late in distal obstruction bowel occurs. There becomes an increased peristalsis ▪ Abdominal distension of the bowel, which in turn leads to secretion of large ▪ Absolute constipation – occurring early in distal volumes of electrolyte-rich fluid into the bowel. obstruction and late in proximal obstruction Bowel obstruction is a surgical emergency. MANAGEMENT INVESTIGATIONS ▪ BEDSIDE: ECG, clinical examination, ▪ INITIAL MANAGEMENT: supportive care urinalysis (fluid resuscitation bowel decompression, ▪ BLOODS: FBC, U&E, G&S, ABG including and analgesia), Nil-By-Mouth, IV fluids, lactate, CRP NG tube with free drainage ▪ IMAGING: abdominal X-ray, erect chest ▪ SURGICAL: emergency resection, X-ray, contrast abdominal CT scan adhesiolysis, hernia repairSMALL BOWEL OBSTRUCTION ▪ AXR: Dilated bowel (>3cm), central abdominal location, and valvulae conniventes visible ▪ Commonly caused by adhesions,he bowel) hernia, and IBD VS ▪ AXR: Dilated bowel (>6cm, or >9cm if at haustral lines visible (lines not completely crossing the bowel) ▪ Commonly caused by malignancy, diverticular disease, or volvulus. LARGE BOWEL OBSTRUCTION LARGE BOWEL VOLVULUS Volvulus occurs when a loop of colon twists around itself and the mesentery that supplies it, causing a bowel obstruction. Caecal Volvulus Sigmoid V olvulus THANKS FOR WATCHINGPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO THE REST OF OUR OSCE SERIES Models: www.biorender.com BMJ best practice https://bestpractice.bmj.com/ Geeky medics https://geekymedics.com/ Zero to finals https://zerotofinals.com/ Radiopaedia https://radiopaedia.org/?lang=gb Teach me surgery https://teachmesurgery.com/ Almost a doctor https://almostadoctor.co.uk/