OSCE Teaching: Session 2

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OSCE Teaching Session 2

• Noor Jawad, Samreen Rizvi and Batool Hariri
• 4th year medics

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Outline of Session

• Abdominal Examination
• Abdominal Histories
• Break
• Inhalers

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Before we start...

• Addendum from last week
• Any questions about the resp exam

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ABDOMINAL EXAMINATION
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Principles of the abdo exam

• Inspection
• Palpation (light and deep)
• Percussion
• Auscultation
• Lots of signs, loads to look for
• Looking at a lot of organs
• Time!

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The Abdominal Examination

• Intro, consent etc.
• Inspection
• Hernia check
• Hands
• Liver flap
• Pulse
• Eyes
• Mouth
• Virchows node

• Inspect chest
• Inspect abdomen
• Light palpation
• Deep palpation
• Liver, spleen, kidneys, AAA
• Ascites
• Auscultation
• Sacral and ankle oedema
• To complete my examination...

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Volunteer!

• Not this week...

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A few questions...

• Could ask if the patient has any tattoos, why?
• What are the abdominal causes of clubbing? (4)

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Clubbing

• Last week we did resp causes
• Bronchial carcinoma
• Cryptogenic fibrosing alveolitis
• Bronchiectasis
• This week the abdo causes
• Cirrhosis
• IBD (CD and UC)
• GI lymphoma
• Malabsorption

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A few questions...

• Could ask if the patient has any tattoos, why?
• What are the abdominal causes of clubbing? (4)
• What is koilonychia and why should you look for
  it?
• Significance of the pulse?
• Why look for pigmentation around the mouth?
• What is angular stomatitis?
• What is atrophic glossitis?
• Significance of Virchows node? What is the sign?
• Where do you start palpating for the liver and
  spleen?
• How do you know it is an AAA?
• What are the 3 types of bowel sounds?

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The 5 Fs of abdominal distension

• Fat
• Fluid
• Flatus
• Faeces
• Foetus

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Now its my turn...
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Issues in the abdo exam

• When to check for the hernia
• Inspection
• Checking for clubbing
• Looking for anaemia and jaundice in the eyes
• Lymph nodes or node?
• Palpating and percussing the organs
• Percussing all over the abdomen
• Ascites check
• HELP

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Any Questions?
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ABDOMINAL HISTORY
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Abdo Hx 1
Introduce self consent Hello I am a 3rd
yr. Patient name, age occupation

• Jaundice
• Change in bowel habit frequency
• Stool blood/black (melaena)/consistency/mucus/fl
  oating (steatorrhoea)
• Diarrhoea
• Constipation
• PR blood/mucus

• PC
• Weight loss
• Change in appetite
• Dysphagia/odynophagia
• Indigestion
• Abdo pain
• Bloating
• Nausea vomiting
• Haematemesis

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Abdo Hx 2

• HPC
• Explore PC and characterise
• PMH
• Happened before
• Known GI disease (!)
• Major illness or ops
• THREADSJ MI
• DH
• Meds plus allergies
• Recreational drug use

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Abdo Hx 3

• FH
• FHx of IBD or gut malignancy
• SH
• Alcohol intake
• Tattoos
• Recent foreign travel
• Sexual history/contacts
• Smoking status
• Family, home, stairs - ADLs

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Abdo Hx 4

• Systems Review
• General weight loss, night sweats, fatigue,
  fever, appetite
• CVS chest pain, SoB, ankle swelling,
  palpitations, PND, orthopnoea, syncope
• GI abdo pain, bowel motions, nv, rectal
  bleeding, haematemesis, weight change, swallowing
  
• GU water works, frequency, haematuria,
  dysuria, menstrual cycle
• Neuro headache, dizziness, hearing, vision,
  pins needles
• Musc joint pain/swelling/stiffness

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Abdo Hx 5

• And finally
• Pt concerns
• Summarise back to pt
• Anything to add?
• Thank you
• Do you have any questions?
• Present back to examiner if appropriate
  differentials

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Volunteer!
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Diarrhoea - Questions

• What does the patient mean by diarrhoea?
• Normal bowel habit
• Frequency over 24h
• Consistency colour, steatorrhoea, offensive
  smell
• Blood/mucus mixed in
• Associated wt loss or other symptoms
• NV
• Abdo pain (SOCRATES)

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Diarrhoea - Questions

• Systemic symptoms malaise, lethargy
• Risk factors foreign travel/recent contacts
• Infective causes ask about -
• Fever, weight loss, night sweats, malaise,
  anorexia, recent travel important

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Diarrhoea - Differentials
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Volunteer!
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Constipation

• Normal bowel habit
• Duration of constipation chronic/acute
• Previous episodes/alternating with diarrhoea?
• Stool blood/mucus/melaena
• Tenesmus
• Rectal disease piles, pruritis, fissures
• Weight loss appetite changes
• Cramps or bloating - ?Ca colon obstruction
• Cancer Weight loss, fatigue, anorexia,
  haemoptysis, fhx, smoking

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Volunteer!
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Haematemesis - Questions

• Characterise nature of haematemesis fresh
  blood/coffee grounds
• Number of episodes/previous episodes
• Volume of blood
• Is there melaena or fresh blood PR?
• Other symptoms epigastric pain, wt loss, ?
  appetite
• Risk factors alcohol XS, peptic ulcer disease,
  oesophageal varices, meds - warfarin

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Haematemesis - Causes

• Oesophageal
• Oesophagitis, carcinoma, oesophageal varices,
• Mallory-Weiss tear, trauma, hiatus hernia
• Gastric
• Gastritis, peptic ulcer, tumours
• Duodenal
• Duodenitis, duodenal ulcer

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Volunteer!
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Rectal bleeding - Questions

• Duration of symptoms yrs, months
• Previous episodes or treatment
• Is the blood
• mixed in with stool
• separate found on toilet paper/splashes in
  toilet bowl
• Fresh or altered blood - ? Lower vs upper GI
  bleed

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Rectal bleeding - Questions

• Main differentials
• Haemorrhoids (piles)
• Colonic carcinoma
• Diverticular disease / bleeding ulcer
• Anal fissure
• Anal carcinoma (rare)

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PEFM, Inhalers, Spacer
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OSCE Station

• Check pt is able to use Inhaler
• Help them use PEFM
• Explain how to use Spacer

• Help a patient manage their breathing problem

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Principles

• Introduction
• Confirm patient name age
• Explain purpose of interview
• Establish how much patient knows
• Explain in a few words the purpose of the device
• Talk through correct procedure to use device
• Check patient has understood (pt demonstrates)
• Asks patient if they have any questions or
  concerns

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Example!

• 20 year old patient has been recently diagnosed
  with asthma. The doctor has asked you to teach
  the patient how to use his/her inhaler and a Peak
  Expiratory Flow meter. Please address any issues
  or concerns they may have.

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Spacer

• Why?
• - Difficulty co-ordinating breathing in
  simultaneously pressing down on the canister.
• - Spacer will deliver more medication.
• What is it?
• - Large plastic container 2 halves that click
  together, mouthpiece at one end and other end has
  hole to insert MDI.

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Spacer contd.

• How it is used?
• - Put two parts together
• - Remove cap of inhaler, shake insert into
  device
• - Place lips around mouthpiece, make tight seal
• - Press the canister once to release a dose of
  the drug
• - Take a deep, slow breath in
• - Hold breath for 10secs then breathe out
  through mouthpiece
• - Breathe in again but do not press the canister
• - Remove the device from the mouth
• - Wait about 30secs before a second dose is
  taken

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A few questions

• Advice to patient that has weak hands?
• What to do if patient has problems with
  co-ordination?
• What to do after using steroid inhaler? Why?
• How often to clean inhaler?
• How to clean inhaler/spacer?
• How often do I use my inhaler?
• What should I do if I forget to take my inhaler?
• Where do I store my inhaler?

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Any Final Questions?
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Next week...

• Neurological examination of the upper limb
• Abdominal histories part 2
• Explaining procedures
• Session 3 _at_ 4pm in R1 (Reynolds)
• Contact us at nj104 sr804 bh04
• See website union.ic.ac.uk/medic/muslim
• Become a MM member if you want priority in the
  mock OSCE!