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OSCEs/ISCEs Moemen Zegugu & Saif Abbas Chatoo Case 1 : Rebecca Rebecca a 43 year old female presents to the emergency department with central diffuse abdominal pain and appears to be in distress. She has also found it very difficult to pass stool for the past three days with occasional watery stools. Four months ago she had a laparoscopic removal of an ovarian cyst with no complications • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 1 : Rebecca DIFFERENTIALS? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 1 : Differentials Small bowel obstruction Large bowel obstruction àAdhesions àColorectal Ca àHernias àVolvulus (sigmoid volvulus) àDiverticular stricture • Topical Anti-viral (Acyclovir) or hloramphenicol Infla ma y b w l d eas Case 1 : Rebecca How would you investigate this patient? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 1 : Investigations Bedside Full abdominal examination including PR examination. Vitals Bloods FBC, U&Es, LFTs, CRP, Lactate, Amylase/Lipase PR and external hernial orifices examination Orifices X-Ray ImagingAXR, Erect CXR, Abdominal CT ECG Routine Special Tests Na Case 1 : Rebecca’s Abdominal Radiograph Firstly confirm patient details, time and date of AXR. Say what you are looking at! Valvulae conniventes à suggestive of SBO • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 1 : Investigations continued Vitals à HR101, RR19, BP 90/55, SATS 89%OA, FEVER 38.5. Mottled appearance, clammy, sweaty. O/E à Diffusely tender abdomen with noted guarding and rigidity. Bowel sounds not present. Erect CXR à Pneumoperitoneum (air under the diaphragm) which suggests a bowel perforation. • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 1 : Rebecca How would you manage this patient? Case 1 : Management Initial ABCDE management. START SEPSIS SIX (patient in shock) “DRIP & SUCK” approach à NBM, IV fluids, and wide bore NG tube ACUTE insertion with free drainage. Catheterise Seek senior support, notify ITU, and urgent general surgeon referral Supportive care with regular monitoring of vital signs. CONSERVATIVE Some cases can resolve with conservative management alone. MEDICAL Pain relief IV antibiotic cover if perforation/peritonitis suspected Depending on the cause à Laparoscopy/Laparotomy SURGICAL Adhesions à Adhesiolysis Perforation repair Colorectal Ca à Emergency resection Case 1 : Key Points to Remember - Bowel obstruction is split into SBO/LBO, each having their own distinct causes - Always remember to order an erect CXR as to not miss a pneumoperitoneum as a perforation can lead to secondary peritonitis and sepsis - Do not forget about colorectal cancer. Features that are a cause of concern include blood in stool, change in bowel habits, weight loss, new iron deficiency anaemia, and appetite loss. Case 2 : Ade Ade, a 63 year-old male presents to the emergency department following multiple vomiting episodes and feeling generally unwell Think about the possible differentials and how you are going to address them in your history! Case 2 : The History PC Reduced appetite Vomiting PMH Liver disease HPC Stroke 4 years ago Hyperlipidemia Onset- 2 days ago OA Gradually worsening DH Vomited 5 times in the last 2 days Atorvastatin Clopidogrel Vomit has a‘coffee ground’ appearanceIbuprofen FH Stools have a horrible stench and darNo relevant FH color SH Feels clammy and cold Heavy chronic drinker (2 bottles of wine a No change in bowel habits before thisday) Non-smoker illness ICE No noticeable pain Worried about who is taking care of his dog at home No dysphagia No weight loss Case 2 : Differentials Variceal bleed Peptic ulcer rupture Oesophageal/Gastric cancer Mallory-Weiss tear • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 2 : Ade How would you investigate this patient? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 2 : Investigations Full abdominal examination including PR examination. Vitals Bedside FBC, U&Es, LFTs, CRP, Lactate, ABG, Coagulation Screen, Bloods G&S, Crossmatch Orifices PR and external hernial orifices examination X-Ray CXR ECG Routine Special Tests Arrange URGENT endoscopy Case 2 : Ade’s Results Vitals à HR 111, BP 93/52, oxygen saturations 92% OA, temperature 37.1 degrees Celsius, capillary refill 4 seconds, peripherally cool and appears confused. Ade’s blood results return. Notable abnormalities include Hb 91g/L (135-180), Urea 14.5mmol/L (2-7), ALT 95 u/L (3-40), ALP 390 u/L (30-100), Albumin 29 g/L (35-50) • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 2 : Ade How would you manage this patient? Case 2 : Upper GI Bleed Management • Initial ABCDE management key for this patient! Insert large bore cannula & NBM • Initiate major haemorrhage protocol & seek senior help! ACUTE • If not responding to fluid resustransfuse (O-ve if crossmatch not ready) • Correct clotting abnormalities and stop any anticoagulants/antiplatelets (clopidogrel) • Suspecting varices à IV terlipressin + initiate broad spectrum Abx • Urgent endoscopy (within 24hours) à endoscopic banding for oesophageal varices, sclerotherapy for gastric varices. • Sengstaken-Blakemore tube / TIPS system if bleeding still uncontrolled • Suspecting peptic ulcer diseaseà IV PPI (AFTER endoscopy), adrenaline injection into bleeding ulcer during endoscopy. • Glasgow Blatchford Score (before endoscopy) • Rockall score (after endoscopy to assess mortality risk CONSERVATIVE and risk of rebleed) • Close monitoring especially if risk of rebleed is high • Refer to alcohol abstinence services if patient agrees • Optimise treatment for liver disease • Medication review Case 2 : Key Points to Remember - In any patient vomiting à ask for colour, appearance - Don’t forget about bowel motions! - PMH/SH key and can help point towards the more likely cause of the upper GI bleed - Any major bleed à activate MAJOR HAEMORRHAGE PROTOCOL! - Upper GI bleed à urgent endoscopy is key! Case 3 : Jasmin Jasmin, a 54 year-old female presents to her GP complaining of increasing right upper quadrant abdominal pain.Case 3 : Jasmin Case 3 : Differentials Acute cholecystitis Malignancy (liver/pancreas) Ascending cholangitis Biliary colic • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 3 : Jasmin How would you investigate this patient? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 3 : Investigations Jasmin’s GP decides to admit her into hospital for further investigation and monitoring Bedside Full abdominal examination including PR examination. Vitals Bloods FBC, U&Es, LAFP/CA19-9Lactate, Amylase/Lipase, PR and external hernial orifices examination Orifices X-Ray US Abdomen! ECG Routine Special Tests Cholescintigraphy (HIDA scan) if diagnosis remains unclear Case 3 : Investigations Vitals à HR 97, RR 18, BP 118/83, 98% oxygen sats OA, temp 38.2 deg Celsius O/E of abdomen à Abdomen generally tender with noted pain on palpation of the RUQ with associated guarding. Arrest of inspiration while pressing over the RUQ with hand. Percussion notes normal. Bowel sounds present. US abdomen à thickened gallbladder wall with stones visualised. Hb 128 g/L (115 - 160) Platelets 312 * 10 /L (150 - 400) Jasmin’s WBC 13.8 * 10 /L (4.0 - 11.0) Blood Bilirubin 16 µmol/L (3 - 17) Results ALP 78 u/L (30 - 100) ALT 29 u/L (3 - 40) Amylase 519 U/L (70 - 300) Case 3 : Jasmin How would you manage this patient? Case 3 : Acute Cholecystitis Management • Initial ABCDE management! • Seek senior help • General surgeon referral • Supportive care and regular monitoring of vitals CONSERVATIVE • NBM • NG tube (if vomiting) • Adequate Analgesia MEDICAL • IV antibiotic cover (as per local guidelines) Definite surgical management is an early laparoscopic SURGICAL cholecystectomy (within 72 hours of symptom onset) as recommended by NICE Case 3 : Key Points To Remember BILIARY COLIC à POST-PRANDIAL RUQ PAIN ONLY ACUTE CHOLECYSTITIS à RUQ PAIN + FEVER/RAISED WCC ASCENDING CHOLANGITIS à RUQ PAIN + FEVER/RAISED WCC + JAUNDICE IMPORTANT TO ASK FOR WEIGHTLOSS, APPETITE LOSS IN HISTORY Case 4 : Monty Monty, a 55 year-old male presents to the ED with severe central abdominal pain and feeling generally unwell. He is known to have hypertension and is a heavy smoker.Case 4 : Monty Case 4 : Differentials Abdominal aortic aneurysm Mesenteric ischemia Ischemic colitis Bowel obstruction • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 4 : Monty How would you investigate this patient? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 4 : Investigations Full abdominal examination including PR examination. Vitals Bedside FBC, U&Es, LFTs, CRP, Lactate, Crossmatch, G&S, Bloods Coagulation screen Orifices PR and external hernial orifices examination X-Ray Bedside US Abdomen! Consider CT if patient stable ECG Routine Special Tests Na Case 4 : Investigations Vitals à HR 104, RR 19, BP 89/49, sats 90% OA, apyrexial. Sweaty, pale, and clammy. O/E of abdomen à Severe pain and tenderness on palpation of abdomen with noted guarding. An expansive pulsatile mass is felt centrally. Bowel sounds present. Bedside US findings à Dilated abdominal aortic aneurysm measuring at 7.4cm, para-aortic fluid collections, and free intraperitoneal fluid. • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 4 : Monty How would you manage this patient? Case 4 : Management • Initial ABCDE management! Insert large bore cannula & NBM • Initiate major haemorrhage protocol & seek senior help! • If not responding to fluid resutransfuse (O-ve if crossmatch not ready) ACUTE • Correct clotting abnormalities and stop any anticoagulants/antiplatelets • IMMEDIATE vascular review and notify an anesthetist • Give prophylactic antibiotics in accordance with local guidelines • Do not waste time doing scans, if hemodynamically unstable + suspecting rupture à straight to theatre for emergency surgical repair. CONSERVATIVE • If survives acute episode will require long term management. • Patient education and lifestyle advice for modifiable risk factorsà smoking cessation advice, hypertensive control, diabetic control, hyperlipidemia control. Case 4 : Key Points to Remember - TRIPLE A is not something to be missed. Consider in anybody with abdominal pain radiating to the back. If missed à consequences are FATAL with mortality close to 100% in the event of a rupture. THIS IS A RED FLAG IF MISSED - Do not forget the major haemorrhage protocol - Do not waste precious time ordering imaging tests if a rupture is suspecting à patient should be taken immediately to theatre. - Lactate is key to help exclude mesenteric ischaemia. - Mesenteric ischaemia à think of this if there is acute abdominal pain with little/no abdominal signs. “out of keeping with physical signs”. Classically Hx of AF. • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 5 : Terry-Jo Terry-Jo, a 63 year-old gentlemen presents to the emergency department complaining of epigastric abdominal pain.Case 5 : Terry-JoCase 5 : Differentials Acute pancreatitis GORD Pancreatic cancer Peptic ulcer disease •M ocaral Anti-virtl (Acyclovir) or Chloramphenicol Case 5 : Terry-Jo How would you investigate this patient? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 5 : Investigations Bedside Full abdominal examination including PR examination. Vitals Bloods FBC, U&Es, LFTs, CRP, Amylase, Lipase, Serum calcium, ABG, Lipid profile Orifices PR and external hernial orifices examination X-Ray US Abdomen for aetiology (i.e., gallstones). Consider CT for more detailed imaging. Acute pancreatitis can be diagnosed without imaging. ECG Routine Special Tests Na Case 5 : Investigation What are you looking for in your investigations? • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 5 : Investigations Vitals à HR 107, BP 118/92, RR17, sats 94% OA, low-grade fever. From your history Terry Jo tells you has been drinking heavily the past few days. O/E of abdomen à Notable tenderness on palpation of the epigastric region eliciting pain which radiates to the back. An area of periumbilical discolouration is seen. Percussion notes are normal and bowel sounds present. 9 WBC 18.1 * 10 /L (4.0 - 11.0) Albumin 27 g/L (35 - 50) Calcium 1.8 mmol/L (2.0-2.5) Glucose 14 mmol/L Amylase 1889 U/L (30-118) • Topical Anti-viral (Acyclovir) or ChloramphenicolCase 5 : Pancreatitis Severity • Topical Anti-viral (Acyclovir) or Chloramphenicol Case 5 : Terry Jo How would you manage this patient? Case 5 : Acute Pancreatitis Management • Initial ABCDE management! Analgesia • Seek senior help and consider for ITU admission • Supportive management is mainstay • Aggressive fluid resuscitation ACUTE • Not routinely made NBM unless clear reason like vomiting • Treat underlying cause/stop any causing medications • Patient education • Continue monitoring for complications which can occurs 1 week later includipancreatic necrosis, pancreatic pseudocyst CONSERVATIVE • Optimise control for any potentialhyperlipidaemia, hypercalcaemia, medication review. IV antibiotics only if signs of infection in accordance with local MEDICAL guidelines Dependent on underlying cause Gallstones à cholecystectomy SURGICAL Biliary obstructionà ERCP Abscess/necrosis à drainage Case 5 : Key Points to Remember - If suspecting pancreatitis à think about the causes to help guide your history and management - Assessing the severity is key to guide management - Management is generally supportive - IV FLUIDS, IV FLUIDS, IV FLUIDS - Remember that an important cause of a ‘medical acute abdomen’ is a myocardial infarction and should always be on the radar. Other medical causes include IBS, gastroenteritis, thyroid • To ical Anti-viral (Acyclovir) or Chloramphenicol dysfunction, and DK . Thank You! This was our last session of the ISCE/OSCE seriesL – Our 3 series !!!! We hope it was useful. We will be back with more soon! To help you ACE! medical school. 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