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OSCE examinations > Abdomen: Common Presentations, Acute Conditions > Flashcards

Abdomen: Common Presentations, Acute Conditions Flashcards

1
Q

What are the key UGI symptoms you want to ask about

-what could they be indicative of?

A

Jaundice - hepatitis, cirrhosis, biliary obstruction (GS, pancreatic cancer?)

Mouth ulcers - B12, Fe, folate def, Crohns?

Vomiting - infection, GORD, bowel obstruction (bilious), cancer?

Hematemesis - bright red (Mallory Weiss tear, esophageal variceal rupture) coffee grounds (gastric/duodenal ulcer?)

GERD - worsened by lying flat, better with antacids

Dysphagia - esophageal cancer
Odynophagia - esophageal obstruction?

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2
Q

What are the key LGI symptoms you want to ask about

-what could they be indicative of

A 
Abdo pain (local/general)
-ECTOPICS, AAA!

Abdo distension - ascities, constipation, obstruction, cancer?

Constipation - dehydration, decreased motility, medications?

Diarrhoea - infection (CDiff), IBD, IBD, cancer

Steatorrhoea - pancreatitis, pancreatic cancer, biliary obstruction, celiac, orlistat?

Melena - UGI blood (peptic ulcer?)

Hematochezia - hemorrhoids, anal fissure, lower malignancy

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3
Q

What systemic symptoms would you like to ask about

A 
Anorexia
Weight loss - malabsorption/malignancy
Nausea
Fatigue
Fever - infection? => appendicitis, diverticulitis, meningitis, pancreatitis
Itch - cholestasis?
Confusion - hepatic enceph?
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4
Q

Possible causes for abdo pain in specific regions

A

RIF - appendicitis, Crohns, ectopic?
LIF - diverticulitis, ectopic?

Epigastric - esophagitis, gastritis?

RUQ - cholecystitis, hepatitis?

Flank - renal colic, pyelonephritis

Suprapubic - UTI

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5
Q

GI risk factors?

  • past medical history
  • FHx
  • Social
A

Preexisting GI disease - GORD, Crohns
Past abdominal surgery - adhesions

FHx - FAP? GI cancers

Social - alcohol, smoking, recreational drugs, diet?

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6
Q

Travel history?

-when would you do this?

A

If likely to be infective?

Where did they go, what did they do
Diet?
Insect bites?
Contaminated water?
Any vaccinations before travel? - malaria prophylaxis
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7
Q

Past medical history

A

Past procedures, surgeries - bowel resection, endoscopy, colonoscopy?

Laxatives, loperamide?
Antacids
PPIs, H2 rec ant?
Immunosuppresants?

Any SE of meds?

  • aspirin, NSAIDS - GI bleeds
  • opiates - constipation, nausea
  • penicilin - hepatitis
  • ondasetron - constipation
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8
Q

FHx of GI disease

A

GI cancers - FAP, Lynch, KRAS, BRCA?

IBD

Age of diagnosis and passing if relevant

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9
Q

SHx

A

Pack years - GI cancer, Crohns
Alcohol - GI malignancy, alcoholic hepatitis, pancreatitis
IVDU - Hep B, C
Diet - low fibre, fluid => constipation
-foods that trigger pain (fat and biliary colic, gluten => celiac)

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10
Q

Key questions to ask for C/D/V

A

Frequency, volume, consistency

Colour and contents

  • blood in vomit => fresh or old?
  • blood in stool => fresh or old?
  • mucus in stool => could be colon issue
  • billous vomit => BO?

Anorexia, weight loss => malignancy?
-colorectal, stomach, esophageal?

Anemia
-Fe, B12, folate diet? => absorption issue/GI bleeding?

GI systems review

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11
Q

GI systems review

-work down body

A 
Difficulty or pain swallowing
Reflux
Indigestion
N+V
Abdominal pain
Changes in bowel habits => constipation, diarrhoea
Blood in stool, vomit
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12
Q

Key questions to ask for dysphagia

A

Difficulty swallowing solids, liquids or both

  • Solids only => mechanical obstruction (cancer?)
  • Solids and liquids => neuromuscular issue (scleroderma, achalasia?)

Constant/intermittent/progressive
-further help differentiate between physical obstruction or neuromuscular issues

Pain on swallowing => weight loss?

Neurological systems review - stroke, PD, MG, ALS, dementia, bulbar localisation
Work down body
-decision making, memory, seizures and falls, behaviour, sight, hearing, balance and dizziness, taste, weakness, tingling, bowels and bladder

GI review

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13
Q

Key questions to ask for indigestion/heartburn

A

Explode as pain
GI review
Screen for MI

Red flags for cancer - anemia, weight loss, anorexia, recent onset progression, melena, dysphagia

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14
Q

Systems review that may aid in diagnosis

A

General
-fever, sweats

Urology
-FUNDWISE B

Gynae

  • pregnant?
  • intermenstrual, post coital, post menopausal bleeds
  • discharge
  • painful periods, dyspareunia, pelvic pain
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15
Q

Possible non abdo differentials for abdo pain

A

MI

  • cardiac risk factors
  • ACS-like

Pnemonia
-resp risk factors

DKA
-ketotic breath, blurry vision, N+V, reduced consciousness

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16
Q

Appendicitis vs diverticulitis

  • risk factors
  • core features
  • investigations
  • management
A

Appendicitis risk factors
-young

Core features
Intermittent E => constant severe RIF pain
Anorexia, nausea, C+D
Fever
Rovsings, Psoas

Peritonitis and rupture - widespread guarding => CXR pneumoperitoneum

Investigations - clinical diagnosis

  • high WCC, CRP
  • abdo US to rule out other pelvic causes

Management
Supportive - analgesia, fluids, ABx
Definitive - appendectomy

Diverticulitis risk factors
-older, low fibre

Core features
LIF pain, C+D
Fever

Investigations - abdo CT
-high WCC, CRP

Management
ABx, analgesia, low fibre
Prevention - high fibre, hydration, physical activity

17
Q

Pancreatitis

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • gallstones
  • alcohol
Core features
Constant E abdo pain, N+V+D
Fever
Onset within 24-48hrs
Cullens, Turners

Investigations - high amylase, lipase
-LFT, US - GS

Management
Supportive - fluids, analgesia, NBM until nausea+pain improve
Definitive
-GS - cholecystectomy
-alcohol - reduce intake
Complications
-drainage of abscesses, debridement of necrotic tissue + IV ABx

18
Q

Cholelithiasis, cholecystitis, choledocholithiasis, cholangitis

  • risk factors
  • core features
  • investigations
  • management
A

Gallstone risk factors
-fat, 40, female, fertile

Cholelithiasis - intermittent RH pain with fatty foods
Cholecystitis - constant RH pain, fever
Choledocholithiasis - obstructive jaundice
Cholangitis - fever, obstructive jaundice, RUQ pain, confusion, shocked

Investigations

  • abdo US - GS
  • stool, urine sample - obstructive jaundice
  • LFT - cholestatic, hepatic if bile backing up into liver
  • High WCC if inflammed

Management
Supportive - fluids, analgesia, ABx
No inflammation - elective cholecystectomy
Inflammed - cholecystectomy
CBD involvement - ERCP GS removal + cholecystectomy

19
Q

Peptic ulcers

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • NSAID use
  • smoking, alcohol, stress
  • FHx

Core features
Indigestion, N+V
Worse with spicy
Better with milk, alkalis

Investigations
HPylori test - urea breath/stool test
ODG + biopsy - confirm ulcer

Management
Address cause
-HPylori eradication - amox+claryth+metro, recheck in 4-6wks
-stop NSAIDs if possible, reduce alcohol, stress, smoking
Supportive - PPIs, can add alginates/antacids

20
Q

Bowel obstruction

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • past abdo surgery
  • hernias
  • malignancy, Crohns, diverticulosis

Core features
Abdo pain, distension, no flatus/feces, N+V
Tinkling bowel sound

Investigations - AXR, CT (dilated bowel loops)
-ABG lactate - any ischemia

Management
Conservative - drip and suck (IV fluids, NG suction, urinary output monitoring
Surgical - laparotomy if cause unlikely to resolve

21
Q

Renal/ureteric colic

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • dehydration
  • FHx

Core features
Loin to groin intermittent pain
Haematuria, dysuria, urinary frequency

Investigations - Xray, CT KUB to confirm stone

Management
Supportive - simple analgesia, fluids
Definitive
-watchful waiting if likely to pass 
-surgery - shockwave/ureteroscopy
22
Q

UTI

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • past UTI
  • sexually active
  • low estrogen
  • DM, obesity, IC
  • stones, surgery, catheters, pregnant

Core features
FUND

Investigations - clinical diagnosis
-urinedip - leukocytes, RBC, nitrites

Management
Definitive if symptomatic - nitrofurantoin/trimethoprim
-treat if pregnant or catheterised
Supportive - remove catheters, fluids, perineal hygiene

23
Q

Endometriosis

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors
-FHx

Core features
Pain on urination, defecation, sex, menstruation
Heavy periods
Difficulty getting pregnant

Investigations
-pelvic US, laparoscopy

Management
Supportive - analgesia, contraception
Surgery - removal of endometriosis tissue, hysterectomy

24
Q

GI investigations you may consider

-which ones must you never forget!

A 
Bedside
Abdo exam
Groin, hernia exam
DRE
NEVER FORGET PREGNANCY TEST!
Urinedip, MSC, stool sample
Bloods
FBC - inflammation, anemia, 
CRP, ESR
LFT - cholestatic or hepatic issue
U&E - kidney function
BM - diabetes
Amylase, lipase - pancreas function
INR, G&S - if surgery needed
Blood culture - infection 
Imaging
CXR - pneumoperitoneum
AXR -
Abdo US
Pelvic US
CT
25
Q

CDiff infection

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • older age, IC, exposure
  • recent surgery
  • ABx treatment - clindamycin, coamox, cephalosporins, ciproflox

Core features
Abdo pain, diarrhoea

Investigations - CDiff toxins in stool

  • high WCC
  • U&E - severity of fluid loss

Management
Supportive - fluids, stop ABx, analgesia
-stay at home until diarhhoea free for 48hrs
Definitive - vancomycin 10 days

Complications

  • toxic megacolon - constipation, distenstion
  • perforation, peritonitis
26
Q

Pyelonephritis

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors

  • sexually active
  • stones, stents, catheters, pregnant
  • IC, DM, obese

Core features
Fever/rigors + flank pain + N+V
UTI presentation
Watch out for sepsis

Investigations - urinedip and MSU

Management => A&E
Broad spec ABx => narrow when MSU results out

27
Q

Coeliac disease

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors
-FHx (T1DM, coeliac, AI thyroid)

Core features
GI - mouth ulcers, abdo pain, diarrhoea, steatorrhea
Skin - dermatitis herpetiformis
Systemic - Weight loss, fatigue

Investigations
Initial - IgA transglutaminase, total IgA
Definitive - intestinal biopsy for villous atrophy, crypt hyperplasia,

Management
Definitive - gluten free diet (avoid wheat, barley, rye)
Supportive - annual review (height, weight, diet, nutritional deficiency check)
Resources - Coeliac UK

28
Q

Crohns vs ulcerative colitis

  • risk factors
  • core features
  • investigations
  • management
A

Risk factors for IBD

  • FHx
  • smoking (protective in UC, damaging in C)
  • appendectomy protective in both

Core features of Crohns
GI - mouth ulcers, abdo pain, diarhoea
Systemic - weight loss, fatigue, joint swelling, eye pain

Core features of UC
GI - abdo pain, bloody diarrhoea, urgency
Systemic - weight loss, fatigue, joint swelling, eye pain

Investigations
Rule out or in
-FBC - anemia from malabsorption/blood loss
-CRP, ESR - active inflammation
-U&E, LFT - dehydration, electrolyte disturbances, disease activity
-ferritin, B12, folate, VitD - nutritional deficiencies from malabsorption
-coeliac IgA tga - rule out celiac
-stool microscopy, culture - rule out CDiff, GI infection
-fecal calprotectin - GI inflammatory marker
Definitive - colonoscopy + biopsy

Management
Acute - CS
Maintenance
-Crohns - thiopurine
-UC - 5ASA/thiopurine
-can escalate to biologics (infliximab - TNFa)
Support - NHS website, Crohns and Colitis

29
Q

Ruptured AAA

  • presentation
  • specific investigations
  • specific management
A

Severe generalised pain

  • back pain
  • low GCS, collapse
  • widespread guarding tenderness

Urgent abdo US, CT angio

Immediate management
-2 wide bore IV cannulas - fluid resus, permission hypotension
-ACTIVATE MASSIVE HEMORRHAGE PROTOCOL
Definitive management
-urgent surgical repair (open/endovascular if stable)

30
Q

Peritonitis, perforation

  • possible causes
  • presentation
  • specific investigations
  • specific management
A

Causes - perforated from

  • peptic ulcer
  • appendicitis, diverticulitis
  • toxic megacolon from CDiff, IBDs
  • ectopics

Severe generalised abdo pain
-widespread guarding, tenderness

Investigations

  • erect CXR - pneumoperitoneum
  • CT abdo, pelvis - locate perforation

Immediate management
-2 wide bore IV cannulas - fluid resus
Definitive management
-urgent surgical repair

31
Q

General hospital management

  • immediate
  • surgery
A

IV fluids
Analgesia (WHO ladder)
Antiemetics

VTE prophylaxis - antiembolism socks, dalterparin unless surgery in U2hrs

Surgery needed

  • NBM
  • INR, G&S
  • stop AC/AP
32
Q

Upper GI bleed management

  • possible causes
  • investigations
  • initial management
  • specific treatment of acute bleeds
  • prevention of future bleeds
A

Variceal - from liver disease
Non variceal - peptic ulcers, cancer, MW tear, esophagitis

Examination for common causes
Variceal - signs of liver disease
Non variceal - signs of cancer

Bloods

  • FBC - acute/chronic blood loss
  • CRP - inflammation
  • LFT, coagulation screen - liver disease
  • U&E - dehydration
  • INR, G&S/M

Initial management - A-E

  • 2 wide bore cannulas, urinary catheter - IV fluid resus to maintain BP, monitor UO
  • if needed, trigger massive hemorrhage protocol - transfuse blood, FFP, platelets
Clotting abnormality management
Stop AC/AP
Warfarin - give PTC, VitK
DOAC - give idarucizumab for dabigatran, andexanet alfa for -bans
Plt U50 - platelet transfusion
High INR - VitK or FFP
Fibrinogen U1 - cryoprecip

Specific treatment of acute variceal bleeds
-terlipressin, IV ABx, endo band ligation
Specific treatment of acute non variceal bleeds
-IV PPI, endo laser/clips

Varices
-propanolol, banding, TIPPS
Non variceal - treat underlying cause
Peptic ulcer - PPI + HPylori investigations/avoid precipitants

OSCE examinations (142 decks)

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