GI OSCE History and Examination

Dr James Young and Dr Anand Goomany

Introduction
OSCE orientated aims:
Cover common Gastro presentations from syllabus:
Provide systematic differentials Suggest targeted Investigations Management and Paperwork

Hints + tips Increase confidence identify strengths and weaknesses

General OSCE Hx Tips

Multiple task stations
Differentials, Investigations, Management, Explanation, Paperwork

Wont tell you to move on Present in categories Focused history and show evidence of Red flags/differential Practice make up own scenarios

 Dysphagia

Dysphagia and Dyspepsia

Mouth/tongue e.g tonsilitis, epiglottitis Extrinsic Goitre, >LA, lymph glands Wall disorders Stroke, Myasthenia gravis, Bulbar palsy, Achalasia, scleroderma, oesophageal spasm, MS Intrinsic Benign/malignant stricture, barretts

Dyspepsia
Functional, H.pylori, GORD, PUD, Ibs Gastritis, Oesophagitis, UGI Bleed, Biliary tree pathology, PE, Pancreatitis Ca, Pericarditis, Myocarditis, Pneumonia

Key questions
Dysphagia
Duration? Location? Worse/better when? Solids/liquids? Painful? Weight loss etc

Dyspepsia
Worse/better when? Painful? IHD? Meleana? Vomiting? In hospital clexane? ALARM Symptoms, VBAD Melaena (remember Fe supplements) Family History

 You are an FY1 on MAU. Please take a focused history from this 54 year old gentleman who has been sent in by the GP with a Hb of 8.3, provide possible differentials, and explain any investigations you will be ordering. Artistic license. 54 yr old. Been getting very bad heartburn recently, esp after meals and at night. Tender at top of tummy. No swallowing problems. Weight loss 1 stone in 6months, decreased appetite. Smoker, high alcohol intake, regularly takes NSAIDs. Meleana several times recently (only if asked about bowels/colour). Was due to attend a breath test of GPs but didnt go. PMH ihd. Dhx aspirin, ibuprofen, omeprazole

Case 1

Peptic Ulcer
DU x2/3 more common than PU burning prior to meals and at night 50% asymptomatic Very strong association with H.pylori, NSAIDs and smoking Urease breath test +/- OGD Complications: perforation, gi bleed Treatment: PPI, h.pylori eradication

Upper GI Bleed
Causes good history/exam and quick flick through notes:
Variceal Bleed
Oesophageal or gastric

Non Variceal
PUD 35-50% Oesophagitis 5-15% MW Tear 15%

Other
Aortoenteric fistula, malignancy, coagulopathy, epitaxis, AVM

Case 2
You are the FY1 on nights covering the Elderly, cardiology and gastro wards. You are bleeped by the gastro ward. Answer your bleep and be ready! Practical Station at the end of practical aspect you will be asked to complete some paperwork.

GI bleed Management

GI bleed - ABCDE
Shocked
A NBM, suction B o2 RE BLEEDS! >HR, <BP (late), <UO 40% who re bleed die

Not shocked
X2 Cannula

C IV fluid, bloods, XM 6units +/- transfusion

Correct clotting abnormalities vit k, FFP Catheterise + monitor UO OGD - <4hrs if shocked + severe bleed

Slow fluids
FBC, U+E, lFTs, G+S, Clotting

His Hb comes back at 7.9 (12.5). What would you do? Please complete relevant paperwork. What medication would you give acutely if you suspected a variceal bleed? dose+route

Rockall Score
0 1 60-80 SBP >100, HR>100 2 >80 SBP <100 Major, CHF, IHD Renal + liver failure or Malignancy 3

Age Shocked Co Morbidities

<60 No None

Diagnosis
Bleeding visible

MW or Normal
None

All others

Malignancy
Visible blood/clot, spurting vessel

<3 = good prognosis, >8= high risk of mortality.

Jaundice
Differential:
Pre Hepatic
Hameolytic malaria, sickle cell, spherocytosis, thalassemia Bilirubin defect Gilberts, Crigler Najjar

Intra Hepatic
Hepatitis, hepatotoxicity, cirrhosis, alcoholic liver disease, Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis, haemochromatosis, wilsons

Post Hepatic
Choledocolithiasis, Pancreas Ca, Cholangiocarcinoma, pancreatitis, pancreatic pseudocyst, Mirizzis, cholangitis

Key Questions
Painless or painful?
When worse/related to food?

Alcohol Fever? Previous episodes? Urine and Stool colour? PMH previous stones, hepatitis risk factors, IBD, liver pathology, autoimmune diseases

 You are an FY1 on SAU. Please take a focused history from this very yellow looking patient. Summarise your history and any investigations you wish to order.

Case 3

Amy, 36. Just returned from a trip to Thailand. Still living the life food, booze and the odd man. Been having crampy upper abdo/ruq pain for a few weeks after food esp fatty foods (only if asked), >30mins. Tried going on a diet lasted 1 day. Previous IVDU and rarely uses contraception. Urine very dark and stools very pale. PMH gallstones (only if asked).

Choledocolithiasis
Gallstones (choleliths)
Cholelithiasis = stones in the GB Choledocolithiasis = gallsontes in the bile duct

Cholesterol supersaturation, accelerated nucleation and GB hypomobility Risk factors

5Fs

Complications
Cholecystitis, cholangitis, pancreatitis, Mirizzis

Investigations
LFTs, amylase+lipase, clotting, USS, MRCP

Treatment
ERCP, Cholecystectomy

Diarrhoea
Causes - Anatomical:
Colonic
IBD Ischaemic colitis Ca Diverticular disease Coeliac Crohns Radiation Lymphoma

Small bowel

Pancreas insufficiency
Chronic pancreatitis Ca CF

Functional IBS Endocrine Hyperthyroidism Iatrogenic, Drug SEs, Faecal impaction

Key Questions
Time frame acute or chronic? Blood? Mucus? Weight loss? Abx use? Food contact? Occupation? PMH Thyroid, IHD, AF FHx IBD

Case 4
FY1 clerking on MAU. Next patient is Brian, 63, who has come in with diarrhoea which he describes as pooing through the eye of a needle. Please take a focused history and offer a differential diagnosis, explanation and potential management to the patient. Please also write what investigations you would like to do (if any). Artistic license with history. Key facts: Brain 63, builder. Abdo pain crampy, constant. Abdo not bloated. Ongoing diarrhoea for 5 days a lot! Now dizzy. Watery and have become more green. Recently had Abx from an old style GP who always gives him Abx, began with a C. No PR blood. PMH IHD, GORD (on ppi), COPD

 Abx induced (4-9day but up to 8 weeks) Produces 2 exotoxins A+B

Increased vascular permeability and pseudomembrane formation

C.Diff

5-20% recurrence Risk factors

Age, hospitalisation, c.diff, loose stools

Blood stool immunoassay for toxins a+b May require sigmoidoscopy or colonoscopy. Treatment 1. Metronidazole 2. Vancomycin, stop abxs, hygeiene Complications Ileus, perf, peritonitis and toxic megacolon

What is this sign? What causes it? What procedure may be used to treat this? Ascites Portal Hypertension Paracentesis riisk of spontaneous bacterial peritonitis

What investigation is this? What is the diagnosis? What histological changes would you expect? OGD Barretts Oesophagus Squamous to columnar

What investigation is this? What is sign called and what is the diagnosis?

Barium enema Apple core sign rectal carcinoma

Name the abnormality? Name two causes of this?

Pneumoperitoneum Bowel perf and post laparoscopy

What is the diagnosis in the diagrams above? (2) List 4 causes. Outline initial treatment. Large and small bowel obstruction Constipation, hernias, adhesions, tumours, crohns, gallstone ileus, volvulus

Name the investigation. Label a,b,c and d. What is the diagnosis?

MRCP A GB+Stones, B CBD + stones, C Panreatic duct, D

Examination

Previous Stations
2005 major lymphadenopathy
RUQ pain (murphys sign) Jaundice and hepatomegaly Scar

(according to Ask Dr Clarke)

2010 Stoma, Renal transplant, scar

2011 Renal transplant

2006:
RIF pain Renal transplant

2007: -Renal transplant -hepatomegaly -Crest Syndrome(!!! Unlikely to come up again!!) 2008:
-hepatomegaly

-Renal transplant -inguinal hernia Stoma

2009:
-Renal transplant

-Inguinal hernia -Abdo pain

Renal Transplant

Renal Transplant
General Inspection Sallow complexion Excoriations Dyspnoea, Oedema (pitting) Bruising Corticosteroid use? SCC Hands Brown nail tips Pale palmar creases Arms Fistula Describe where the fistula is wrist (radio-cephalic); Antecubital fossa (brachio-cephalic) Palpate for a continuous thrill Auscultate for a continuous murmur Face Eyes pale conjunctiva, periorbital oedema Mouth Halitosis, Gum Hypertrophy (ciclosporin)

Neck/Chest Vascular access scars Previous parathyroidectomy scar?

Abdomen Hockey Stick scar (Rutherford-Morrison scar) Look for nephrectomy scars in loins going round to the back Peritoneal dialysis catheter scars around umbilicus Palpate for native kidneys often left in situ and may be ballotable Mass in RIF, sometimes LIF Palpate and describe Ask patient to lift head off the bed Ask patient to cough

Differential Diagnosis
RIF mass
GI: Bowel/caecal malignancy Appendix mass/appendix abscess Crohns disease Grossly enlarged GB

Gynae: Ovarian tumour Ovarian Cyst

Other Psoas abscess Enlarged lymph nodes External/common iliac artery aneurysm

LIF mass GI:

Bowel/sigmoid malignancy Constipation Diverticular mass

Gynae and other causes as above

Hernia Examination

Hernia Examination Basic Anatomy

The mid-inguinal point: Found half-way between the Anterior Superior Iliac Spine and Pubic Symphysis. This marks the point where the femoral pulse can be palpated. The mid-point of the inguinal ligament: Found half-way between the ASIS and Pubic Tubercle. This landmark signifies where the deep (internal) inguinal ring lies. This can help to determine whether the hernia is direct or indirect, whilst carrying out a clinical examination. The superficial (external) inguinal ring is the end of the inguinal canal. It lies superior and medially to the pubic tubercle.

The Examination
Examine lying and standing Expose adequately Ask about pain again Inspection Site, size and shape Extension into scrotum Colour/health of surrounding skin Surrounding scars Any other groin swellings look at both sides! Ask patient to cough Palpation Palpate hernia consistency, temperature, tenderness, surface, borders, fluctuance, pulsatile, can you get above it? Palpable cough Impulse?

Reducibility
Ask the patient to reduce the hernia first Then apply firm pressure with 1 or 2 fingers over the deep inguinal ring Ask patient to cough again

If the hernia is controlled -> Indirect inguinal hernia If the hernia is not controlled -> Direct inguinal hernia (or femoral hernia)

In practice the only real way to distinguish between different types of groin hernias is intraoperatively Percussion and auscultation
Resonant hernia more likely to contain loops of bowel Auscultate for bowel sounds Omentum and fat is dull to percussion and has no bowel sounds Books say to do this, doesnt add much clinically

Differential Diagnosis of an Inguinal Hernia

(learn the causes of scrotal masses as well)

In a male Hydrocoele of the spermatic cord Spermatocoele Varicocoele Lipoma of spermatic cord In a female Hydrocoele of Canal of Nuck Both sexes Femoral hernia Lymphadenopathy Groin abscess Haematoma following trauma or haemorrhage

Stomas

Stoma Examination
Site RLQ/LLQ? Bag Liquid/solid? Blood Mucus Surface Flush with skin/protruding spout? Single lumen (end)/double lumen (loop)? (sometimes difficult to see) Health of mucosa and surrounding skin (erythema, rash, ulceration) Surrounding scars Ask patient to cough (?parastomal hernia)

Ileostomy Indication Panproctocolectomy (eg UC) - End ileostomy Anterior resection (eg colorectal cancer) Loop ileostomy Site Stool Surface Right lower quadrant Continuous and fluid Spout raises stoma from skin

Colostomy Abdominoperineal resection or Hartmanns procedure (eg bowel cancer)

Left lower quadrant Intermittent and semi-solid Lies flush with the skin

Summarise .The patient a stoma with two lumens in the left lower quadrant with the mucosa lying flush with the skin. The bag contains semi formed stool and mucus. This is consistent with a loop colostomy. The surrounding skin appears healthy and there is no evidence of a parastomal hernia

Summary

Good Luck!!