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OSCE > GI history and examination > Flashcards

GI history and examination Flashcards

1
Q

What to ask for in GI exam:

A 
Pain
Abdo distension
N&V
Difficulty swallowing
indigestion/heartburn (hiatus hernia, peptic ulceration, barrets)
Hx Gall stones / pancreatitis
Jaundice
Altered bowel habit
Haematemisis / blood in stools
Mucus per rectum
Appetite / Weight change
Continence
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2
Q

SOCRATES for Peptic ulcer

A 
S - Epigastric
O - acute or gradual
C - gnawing
R - into back
A - can give GI haemorrhage, peritonitis if perforated
T - 0.5-3hrs
E - hunger, smoking, alcohol, NSAIDS + aspirin
Alleviated by food, antacids, vomiting
S - mild/moderate
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3
Q

SOCRATES for acute cholecystitis

A 
S - epigastric / R hypochondriac pain
O - constant unpredictable
C - stabbing
R - right scapula / tip of shoulder
A - vomiting, fever, rigors
T - 3-24 hours
E - sometimes food (fatty)
Alleviated by pain relief meds 
S - Severe
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4
Q

Acute pancreatitis SOCRATES

A 
S - epigastric
O - sudden or gradual
C - piercing / stabbing
R - into the back, may get peritonitis
A - nausea & vomiting
T - lasts over 24 hours
E - eating
Alleviated by sitting upright
S - very severe
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5
Q

Causes of vomiting to ask about:

  • Nervous system
  • Systemic conditions
  • Other
A

NS: motion sickness, labyrinthine disorders, migraine, meningitis, inc ICP, Pain (e.g. rena colic, MI)

SC: preg, renal failure, DKA, hyperparathyroid

O: Drugs (due to central action e.g. morphine, or gastric irritation e.g. NSAIDS)

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6
Q

Vomiting Hx

A

How frequently?
What time of day?
Taste, colour, smell and quantity?
Blood (fresh or altered?)

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7
Q

Possible causes of Dysphagia

A

Lesion in mouth or throat

Neurological: e.g. pseudo bulbar palsy

Obstruction at post-cricoid area (e.g. tumour, pouch, stricture)

Obstruction at lower end of oesophagus ( tumour, achalasia, stricture due to acid/barrets)

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8
Q

Dysphagia Hx

A 
Is it continuous or intermittent?
How long does it last fo
Where does the food stick?
Is it to solids, liquids or both?
Does it occur between meals?
Do you get acid reflux?
Does coughing/breathlessness wake you fro sleep?
Do you wake up with funny taste in mouth?

RF for Oesophageal Ca: Smoking, alcohol, obesity, diet lacking veg and fruit

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9
Q

Jaundice Hx

A 
Colour of urien /  stools (differentiates haemolytic fro obstructive)
Hx of gallstones
Pain (Ca pancreas usually felt in back)
Fever & rigors
Itching
SH: Alcohol, drugs, foreign travel ( inc transfusions and tattoos)
Unprotected sex 
(looking for hepatitis picture)
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10
Q

Altered bowel habit Hx

A

How has it altered (diarrhoea, constipation or both?)
Frequency of stools
Abdo discomfort or urgency?
Incontinence?
Appearance of stool (formed or unformed), does it float
Blood/Pus/Mucus
Vomiting?
Foreign travel?
Medications (inc OTC)
Any other assoc (e.g. stress, others affected)

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11
Q

Rectal bleeding Causes

A

Haemorrhoids (generally painless, bleeding is fresh red and separated fro stool)
Carcinoma (assoc with mucus)
Inflammatory bowel disease (pus and mucus)
Diverticular disease
Anal fissure (fresh red, severe pain during and after defaecation)
Melena (severe bleeding from the upper GI tract. Dark colour and may have clots. Pt may be n shock)

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12
Q

Abdominal distension (acute)

A 
Bowel obstruction
Ascites
Ovarian cyst
Undiscovered preg (less acute) 
Chronic constipation
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13
Q

Loss of weight / appetite

A

how much WL over how long?

Associated loss of appetite or due to deliberate reduced intake?

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14
Q

Causes of WL without loss of appetite

A

Ca
DM (T1)
hyperthyroidism
Malabsorption syndrome

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15
Q

GI HPC

A

Previous GI problems / diagnoses (any effective Tx)

Previous GI surgery

Gynaecological problems (pelvis communicated with abdominal?)

Hx of Jaundice / Anaemia / Diabetes

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16
Q

Main drugs with GI SE

A 
Iron
Opiates
NSAIDs
Abx
Anticoagulatns
SSRIs
17
Q

SH for GI

A

Alcohol
Smoking
Recent Foreign travel

18
Q

General inspection GI

A 
Bed area (vomit, tablets etc)
Expose patient fully 
- Colour (jaundice, anaemia)
- Perspiration
- Build (wasting? obesity?)
- Discomfort
- Breathing (rate, diaphragmatic or chest wall?)
- consciousness
19
Q

GI examination hands

A

Colour (palmar crease pallor - anaemia, erythema - oestrogen in Liuver disease0

Temp

Clubbing (in cirrhosis, UC, Crohns, Coeliac)

Leukonychia (white patches on nail plates due to trauma.
Leukonychia totalis - entire nail affected and seen in hypoalbuminaemia e.g. nephrotic syndrome, Liver failure, protein malabsorption)

Koilonychia (spoon shaped - chronic iron deficiency)

Asterixis (Liver flap) - maintain position for 5 sec in OSCE (due to failure of ammonia conversion to urea. also seen with CO2 retention)

20
Q

GI peripheral examination

A

Patients pulse and BP

Examine forearms: muscle wasting, scratches assoc with pruritus, Russels sign (Bulimia), Spider naevi)

21
Q

GI Eye signs

A 
Jaundice
anaemia (ask to pull down conjunctiva)
Xanthelasma
Corneal Arcus
Kayser-Fleischer rings (Wilson's) - seen early on with slit lamp and later with naked eye
22
Q

GI mouth examination

A

Telangiectasia ( hereditary haemorrhage telangiectasia)
Pigmentation (Petz-Jegher: small bowel hamartomas)
Angular stomatitis: B6/12, folate or iron def

Glossitis: painful, smooth tongue seen in B12 or folate def (painless if iron)

Dehydration
Halitosis
Dental caries
Ulcers (B12, iron def, Crohn’s, Coeliac)

23
Q

Central inspection of abdo (make sure adequately exposed)

A

Spider naevi
Gynaecomastia
Scars, stretch marks, skin lesions
Shape and symmetry
Movement during breathing (diphragmatic breathing stops with peritonitis)
Visible swellings or masses / peristalsis / pulsation (aortic)
distended veins (SVC obstruction or portal HTN)

Ask patient to sit forward’s to inspect the back

24
Q

5 Fs of abdo distension

A 
Fluid (ascites)
Faeces (consipation)
Flatus (subacute intestinal obstruction)
Foetus (preg)
Fat (obese)
25
Q

Bed position in GI

A

MUST BE FLAT!

26
Q

GI palpation

A

Across 9 regions Superficial then deep

Organ specific
Liver, Spleen, Kidneys, Bladder, Aorta
In abdo distension succussion splash

27
Q

Palpating the liver

A

Feel edge of liver on inspiration
Ask to breathe out and move hand nearer costal margin.

Liver can be palpated if 1cm below costal margin

Murphys sign (right costal margin, mid clavicular line) positive in acute cholecystitis

28
Q

Palpating spleen

A

not palpable unless enlarged 2-3X

Start in right iliac fossa and advance to left costal margin whilst patient takes deep breaths

29
Q

Kidneys

A

Ballottement

Anterior hand press deeply
Posterior placed in costovertebral angle)

the lower pole of right kidney flat in thin people

30
Q

Aorta and femoral pulses

A

Check for aneurysmal pulsation.

Femero-femoral delay can be seen if aneurysm around lac bifurcation

31
Q

Percussion in abdo

A

Percuss the liver (using fan hand technique)

Spleen: lowest intercostal space, changes from resonant on full inspiration to dull on full expiration (Castell’s)

Percuss down over bladder

If ascitic: shifting dullness

32
Q

Auscultation of abdo

A

Bowel sounds (abnormal = absent in ileus or tinkling in SB obstruction)

Listen with bell for aortic or femoral bruits

33
Q

Overview of abdo

A

Inspection
Palpation
Percusion
Auscultation

34
Q

End piece for abdo

A

ISHRUG

Inguinal lymph nodes
Stools
Hernial orifices
Rectal examination
Urinalysis
Genitalia

OSCE (9 decks)

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