Clinical Skills III

Instructional Book

Gastrointestinal System

Clinical Skills Center

Faculty of Medicine
Pelita Harapan University
Karawaci – Tangerang
Semester IV
2018

 
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 Table of Content

Tutorial 1 – History Taking Vomiting ............................................................................ 4

Basic Gastrointestinal Examination ............................................................................... 6

Tutorial 2 – History Taking Bowel Habit ....................................................................... 13

Diarrhoea ............................................................................................................... 14

Constipation ........................................................................................................... 16

Rectal Bleeding ..................................................................................................... 16

Tutorial 3 – History Taking Jaundice .............................................................................. 20

Tutorial 4 – History Taking Dsysphagia ......................................................................... 25

Tutorial 5 – History Taking Alcohol in Health and Disease .......................................... 29

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The book was adapted from INTRODUCTION TO CLINICAL MEDICINE 2, SEMESTER

2, MELBOURNE MEDICAL SCHOOL, THE UNIVERSITY OF MELBOURNE; with
permission from University of Melbourne

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Tutorial 1 – History Taking

Introduction

During this semester, the focus will be on aspects of the medical interview and physical
examination that relate to the gastrointestinal system. The course material is designed to link
with your studies in the basic sciences of this body system.

The first tutorial provides an opportunity to review the cardinal features of a presenting
problem, applied to the symptom of vomiting. There will also be an introduction to the basic
physical examination of the gastrointestinal system.

Vomiting

Vomiting (or “emesis”) is defined as the forceful expulsion of gastric contents through the
mouth, associated with the contraction of the muscles of the abdominal and chest wall1 The
act of vomiting is under control of the vomiting and chemoreceptor trigger centres in the
brain.

A number of symptoms are associated with vomiting:

(i) Nausea is the unpleasant feeling of needing to vomit. It often accompanies vomiting
but may occur separately from it.
(ii) Dry retching is the term used to describe when muscular contractions occur without
expulsion of gastric contents.

(iii) Haematemesis is the term used when a person vomits blood. It is derived from the
words “haem” meaning blood and “emesis”.

It is important to distinguish vomiting from regurgitation which is the passive flow of

oesophageal contents into the mouth without nausea and the muscular activity associated with
vomiting. Regurgitation typically occurs in the setting of gastro-oesophageal reflux disease.

Vomiting is a very common symptom. It can be caused by a wide range of medical

conditions, such as gastroenteritis, pregnancy, medications (especially chemotherapy) or
acute myocardial infarction. As you gain more medical knowledge, you will be able to ask
questions that help to define the potential causes of this symptom.

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In the meantime, it is important that you can identify the cardinal features from a patient’s
history. Pay particular attention to the relationship of the vomiting to eating. It may be useful
to ask the patient for ideas about potential triggers but remain open to diagnostic possibilities.

Case Study 2.01

Emma Vaughn, a 24-year old university student,

has presented to her general practitioner with
vomiting. She has a history of headaches which
have been diagnosed as being due to migraine.
She is being interviewed by Nick Modrzewski,
a first year medical student.

Watch the interview and write down the cardinal

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The physical examination

The physical examination is an important component of the patient assessment. During your
medical course, you will learn how to examine each of the body systems. Certain general
principles apply to all physical examinations.

Firstly, it is important that the patient is adequately prepared for the examination. He or she
needs to know why the examination is required and in general terms what it will involve
before you proceed.

Secondly, a physical examination needs to be conducted in a way that respects the

patient’s right to privacy. Attention must also be paid to the patient’s comfort and dignity.
Ensure that the environment is warm and well lit.

Thirdly, clear instructions need to be provided so the patient understands what is required of
him or her during the examination. Talking the patient through the process will help to put
him or her at ease and enable you to elicit maximal clinical information.

Like any psychomotor skill, the physical examination requires practice to achieve
proficiency. Left handed students may face an extra challenge as most examination settings
are configured for the right-handed person.

The basic gastrointestinal examination

View the audio-visual segment that demonstrates the basic physical examination of the
gastrointestinal system.

1. Preparing the patient

Start by explaining to the patient the reason for the physical examination and in general what
it will involve. Avoid using medical jargon that the patient may not understand. Ask the
patient to undress to underwear. Where possible, provide a gown or sheet for the patient.
Leave the patient covered for as long as possible during the examination . When you need to
expose the chest or abdomen, ask the patient to lower the gown or sheet. Provide assistance
if you think it is required, but always ask the patient first. Check that the patient is
comfortable and ready to proceed.
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2. Hand hygiene
It is important to wash your hands or apply an alcohol hand rub before commencing the
examination.

3. General inspection
While you are preparing the patient for the examination, make a discreet general
inspection. Take note of the patient’s general mental state and alertness, body habitus such as
cachexia or muscle wasting, jaundice and whether the patient seems distressed or in pain.

4. Examination of the hands

Examine the nails for leuconychia (“white nail”) and clubbing. Also examine for palmar
erythema (“redness”) and pallor of the palmar creases. Feel the palmar fascia for a
Dupuytren’s contracture.

Test for the presence of metabolic flap, also called asterixis. To do this, ask the patient to
hold both arms up with hands extended and arms outstretched. The hands need to be kept
in this position for 15 seconds. A flap is present if there is a flexion-extension movement at
the wrists. A metabolic flap in the setting of advanced liver disease is caused by hepatic
encephalopathy which occurs when high levels of ammonia interfere with brain cell function.

5. Head and neck

Examine the conjunctivae for jaundice. This can usually be detected clinically if the serum
bilirubin level is > 50 µmol/L . You may notice that a patient has conjunctival pallor but this is
not a reliable indicator of anaemia. The absence of conjunctival pallor does not rule out
anaemia.

6. Examination of the chest

Examine the chest and neck area for spider naevi. A spider naevus (or spider angioma)
consists of a central arteriole with small vessels radiating from it, giving the appearance of a
spider. Pressure applied to the central arteriole causes blanching of the whole lesion, which
then refills with blood in the centre part first, followed by filling of the “spider legs”.

Spider naevi are usually found on the neck, chest, arms and back, in the distribution of the
superior vena cava. They are a sign of chronic liver disease but can occur in other conditions

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such as pregnancy or with oral contraceptive pill use. They can also occur in healthy people,
but are usually smaller in size and fewer in number (three or less).

Gynaecomastia, defined as the proliferation of glandular tissue in the male breast, can occur
in chronic liver disease. To examine for gynaecomastia, the thumb and the index finger
should be placed on each side of the breast and used to “pinch up” the tissue to determine if it
is firm breast tissue or fat. You do not need to examine for gynaecomastia at this level of your
training.

7. Inspection of the abdomen

Position the patient for the examination of the abdomen. Ask the patient to lie flat with the
head on one pillow only and with arms at the sides . This position relaxes the abdominal
musculature and makes the examination of the abdomen easier to perform. Ensure that there
is adequate exposure of the abdomen from the xiphisternum to the pubic area.

Look for scars from past surgery (these can be confused with striae which are caused by
stretching of the skin due to pregnancy or obesity), distension or masses.

In the setting of cirrhosis of the liver with portal hypertension, collateral vessels can develop
around the umbilicus (called caput medusae). Distended abdominal wall veins can also occur
in the setting of obstruction of the inferior vena cava (IVC). Testing the direction of flow in
these veins is sometimes done to help distinguish IVC obstruction from portal hypertension
but this is an unreliable test and is not recommended.

8. Palpation of the abdomen

Palpate the abdomen with your right hand. Ensure that your hands are warm before you start.
Ask the patient about tender areas before you begin, if this has not already been elicited
when taking the history. Check that you are not causing discomfort by intermittently looking at
the patient’s face.

Start by palpating lightly, taking note of any tenderness, guarding, rigidity or obvious
masses. Then palpate the abdomen more deeply, feeling specifically for masses and
enlargement of organs. Mentally divide the abdomen into regions while you palpate to

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ensure that you systematically cover all areas of the abdomen. Think carefully about what
structures lie beneath as you move your hands.

(i) The abdomen divided into four regions :

(ii) The abdomen divided into nine regions:

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9. Examination of the liver
Examine the liver. Commence by palpating in the right lower quadrant with your hand flat on
the abdomen and parallel to the costal margin. If you start at this location, you will not miss a
grossly enlarged liver.

Apply firm but gentle pressure with your fingers, especially the index finger. Feel for a liver
edge that moves downwards as the patient inspires, by exerting upward pressure with your
hand. Inspiration causes the diaphragm to push the liver inferiorly, making the liver edge
easier to feel. Advance your hand approximately 2 cm towards the costal margin during
expiration. Remember to palpate all the way along the costal margin, especially towards the
epigastrium. If you feel a liver edge, note its consistency. Is it firm? Are there any masses?
The lower border of the liver can be confirmed by percussing the liver from the right lower
quadrant up to the right costal margin. The percussion note will change from resonant to dull
when you reach the liver edge.

To define the upper border of the liver, percuss from above in the midclavicular line. Start at
about the level of the third rib, and move down one intercostal space at a time. The upper level
of the liver is usually at the level of the sixth rib or fifth intercostal space. Percussion involves
placing your left middle finger flat on the surface that you are examining. Strike the middle
phalanx sharply at right angles with the pad of the right middle finger. Notice how the wrist is
flexible and swinging freely. If you are left-handed it may be easier to use your left middle
phalanx as the percussion finger.

Measure the liver span with a tape measure. The liver span is measured in the midclavicular line.
The normal liver span is 12 – 13 centimetres.

The “scratch test” is sometimes used to determine the lower edge of the liver. The basis of the
manoeuvre is that as you ”scratch” along the patient’s abdomen up towards the right costal
margin, the sound of the scratch , as heard through a stethoscope placed on the abdominal
wall, will become louder as you scratch over the liver. This method of detecting the lower
edge of the liver is unreliable and therefore not recommended.

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9. Examination of the spleen
Start by palpating the spleen. Many methods for palpating the spleen have been reported
Position your right hand parallel to the costal margin, commencing at the umbilicus. Palpate for
the spleen as the patient inspires. Advance your hand towards the costal margin two
centimetres at a time during expiration. Be sure to check along the costal margin. Roll the
patient towards you and palpate again on inspiration. Position your left hand postero- laterally,
applying counter pressure. Having your hand in this position allows you to gently move the
lower ribs anteriorly and medially, making it easier to feel an enlarged spleen.

Usually, the spleen is not palpable. The spleen has to be double its normal size to be
palpable. However, if it is enlarged, you may be able to notice the splenic notch along the
medial border. It is not possible to palpate above the upper border of the spleen, which may
help you distinguish an enlarged spleen from other abdominal masses.

10. Examination of the kidneys

Examination of the kidneys is performed using both hands. The right hand is placed under the
costal margin and the left hand is placed posteriorly in the loin region. The fingers of the left
hand push the kidney forward, while the right hand applies posterior pressure. Ask the
patient to take a deep breath as you do this. An enlarged kidney can be balloted between the
two hands. The kidney is a retro-peritoneal organ which is usually difficult to feel. It may be
possible to feel the lower pole of the kidney in a thin patient.

11. Other manoeuvres

Ascites is an accumulation of fluid in the peritoneal cavity, commonly due to cirrhosis of the
liver. The presence of ascites causes bulging flanks, as the fluid gravitates towards the
flanks. The absence of bulging at the flanks makes ascites unlikely. If inspection does not
reveal bulging, further examination for ascites is not required.

Another sign of ascites is flank dullness, which is the presence of a dull percussion in the
flanks. The percussion note over the abdomen will be resonant, as gas-filled loops of
bowel lie underneath. In the setting of ascites, the note will change from resonant to dull as
you percuss away from the midline out laterally. If flank dullness is absent, the examiner can
be reasonably confident that ascites is not present. You are not expected to be able to detect

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the presence of ascites at this stage of your learning.

Auscultation for bowel sounds is of limited use in most clinical settings. Normal bowel
sounds vary considerably in frequency and intensity. The setting in which auscultation is
most useful is that of bowel obstruction (when they are usually diminished or absent), but
even then there can be huge variability.

The gastrointestinal examination also includes checking the groin for herniae and
performing a digital rectal examination. At this stage of your medical course, you are not
required to perform these examinations.

12. Completing the examination

Inform the patient that the examination is complete and that he or she can get dressed. Offer
assistance if necessary.

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Tutorial 2 – History Taking

This tutorial introduces the symptom of rectal bleeding and the symptoms that relate to bowel habit. It also
provides an opportunity for you to develop your communication technique by focussing on basic reflective skills
and to start practising the basic examination of the gastrointestinal system.

Bowel habit

Bowel habit refers to the pattern of defecation, the mechanism by which the waste products of digestion are
excreted from the body.

The process of digestion is complex. It begins with ingested food being broken into small pieces by mechanical
means, primarily chewing. These small pieces in turn are broken into simple molecules by chemicals, including
acid from the stomach and enzymes from the pancreas. These molecules are absorbed through the small bowel
and transported to cells where they are metabolised into energy.

Undigested material passes as a liquid effluent into the large bowel. The main function of the large bowel is to
extract water from this effluent and convert it into faeces. Faeces, sometimes also called stools, are usually semi-
solid and easy to evacuate through the anus. The formation of faeces, however, can be affected by a variety of
diseases, leading to symptoms such as diarrhoea or constipation.

When interviewing a patient about bowel symptoms, it is important to remember that the normal frequency of
defecation varies in the general population from once every 2 – 3 days to several times per day. A change in
bowel habit from normal may be a more important feature than the actual frequency. It is also important to
remember that many patients feel uncomfortable talking about bowel habits and you need to be sensitive to this.

Because the frequency of defecation varies widely in the general population, always ask about
changes in bowel habit

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Diarrhoea
The word diarrhoea is derived from the Greek “to flow through” and denotes the frequent and
excessive passing of watery unformed faeces. It is usually due to damage to the lining of the
bowel that inhibits absorption of water from the waste products of digestion.
Diarrhoea is usually classified as being either acute or chronic:

(i) Acute diarrhoea

This refers to diarrhoea that has an abrupt onset and a short duration. Acute diarrhoea
mostly lasts only a few days and is usually caused by an infection, such as gastroenteritis or
food poisoning.

(ii) Chronic diarrhoea

The word “chronic” is used in medicine to refer to conditions that are slow to develop and
have a long duration. In the case of diarrhoea, it is used when symptoms have been present
for more than four weeks. Chronic diarrhoea can be caused by a wide range of medical
conditions.

Applying the cardinal features to diarrhoea

Not all the cardinal features are relevant to diarrhoea. There are also additional specific
questions that you will need to ask when a patient presents with this symptom.

Cardinal Feature Notes

Site This feature is of little importance in the case of diarrhoea. The site
of associated abdominal pain, however, may be helpful in making a
diagnosis.
Quality Ask about the nature of the diarrhoea. How watery is it? Is there any
blood or mucus in it?

Severity The severity of diarrhoea is usually judged by the frequency of bowel

action. The volume of the stools may also provide an indication of
severity.
Time Course It is important to distinguish acute from chronic diarrhoea as the
causes are usually quite different. Also establish whether the
diarrhoea is worsening or improving with time.

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Context The context can be important when trying to find out what is causing
the diarrhoea. In the case of acute diarrhoea, ask if any particular
food was associated with onset of the diarrhoea. A recent history of
Aggravating Factors Is there anything
overseas thatalso
travel may makes the diarrhoea worse?
be relevant.
Relieving Factors Is there anything that seems to relieve the diarrhoea? Has the patient
tried taking anything for the diarrhoea? If so, how effective was it?

Associated Features As you learn more about diseases that cause diarrhoea, you will be
able to ask specific questions that can help point to a diagnosis. In
the case of acute diarrhoea, which is usually caused by an infection,
ask if there has been any associated nausea and vomiting or if any
contacts have also been affected.

Case Study 1.19

Kirk Johnson, 26, has presented to the Emergen-

cy Department with acute diarrhoea after arriving
home from travelling in South-East Asia. He is
speaking with Nick Modrzewski, a first year medi-
cal student.

Write down the cardinal features of Mr Johnson’s

presenting problem. Comment on the words that
he used to describe his illness.

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Case Study 1.20

Anna Russo, a 3 32-year old mother of two, has been

referred to Gastroenterology Clinic with a problem of
chronic diarrhoea. She is talking with Dr Penny Hogan,
who is a trainee gastroenterolo- gist.

Write down the cardinal features of Mrs Russo’s

presenting problem. Compare her presentation with
that of the patient in Case 1:20.

Constipation
Constipation is a very common digestive problem. It refers to excessively hard stools, usually
caused by increased absorption of liquid as a result of slow transit through the large bowel. It
may be associated with a reduction in the frequency of defecation and a feeling of incomplete
evacuation of the bowels. Some patients need to strain in order to pass their stools. Constipation
is often caused by a low fibre diet but can be caused by medications or certain medical
conditions.

Rectal bleeding
The passage of blood or clots from the rectum is a common medical condition. The technical
term to describe this is haematochezia. The amount of blood lost can vary from a few spots to
an amount severe enough to cause symptoms of anaemia.

Rectal bleeding is often caused by benign problems such as haemorrhoids or an anal fissure
but can be a sign of colorectal cancer. The presence of blood in diarrhoea may indicate the
presence of inflammatory bowel disease.

The colour of the blood can point to the likely site of origin. In general, the blood is usually a
brighter red if the source is close to the anus. Bleeding from the first parts of the large
intestine will often cause the passage of darker or maroon-coloured blood that is more likely
to be mixed in with the stools.

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When the bleeding originates from the upper gastrointestinal tract1, the stools usually appear
black and tarry and this is called melaena. The stools appear black because the blood is
oxidised by bacteria as it passes through the intestines. Upper gastrointestinal bleeding can
manifest as haematemesis or melaena. Rarely, if the bleeding is severe, it can present as
haematochezia.

Case Study 2.02

Julie Davidson, a 55-year old office

worker, has developed a problem of rectal
bleeding. She is being interviewed by
Tess McClure, a first year medical
student.

Watch the interview and record the cardinal fea-

tures of Ms Davidson’s presenting problem. Iden-
tify the likely site of origin of the bleeding.

Building on your communication skills

During the previous semester, you were introduced to the use of basic active listening skills
during a medical interview. These skills included facilitation using both verbal and non-
verbal encouragers. You also learned how to clarify what the patient had said in order to
check that you had understood what they were saying.

Another useful communication skill that can be used to facilitate the interview process is
called reflection. This involves reflecting back to the patient what he or she has just said.
It can be done by repeating or restating exactly what the patient has just said or paraphrasing
it by briefly summarising the content using your own words.

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Repetition or restatement
Repeating the last few words that a patient has said is called repetition or restatement2. It
is also sometimes called “echoing”. This communication device can help signal to the patient
that you are listening carefully to their narrative and can also encourage them to keep talking.
Tess McClure used repetition during her interview with Julie Davidson:

JULIE DAVIDSON: “Well … I’ve noticed bleeding when I go to the toilet … when I you
know … when I use my bowels … ”

TESS MCCLURE: “ … when you use your bowels …. “

Paraphrasing
Paraphrasing means restating what the patient has said in your own words. It can act as a
summary of what the patient has just said and can be used to check that your interpretation of
the information is correct. Paraphrasing combines facilitation, summarising and clarification.
Tess McClure used paraphrasing during her interview with Julie Davidson

JULIE DAVIDSON: “… I wasn’t sure what to do about it. I started taking a laxative
again last weekend but my stools are still quite hard and I’m still straining when I go to the
toilet …”
TESS MCCLURE: “So the laxative hasn’t really been effective as yet …. “
JULIE DAVIDSON: “No, not yet … but I’ve started to eat more fruit and vegetables and
drink lots of water as I know that can help as well.”

These communication skills may seem quite straightforward but can be difficult to apply
when you are also concentrating on the content of the interview. Practise using these
techniques during general conversation as well as while you are interviewing patients.

Role Play
Use role play to practise interviewing about bowel habit and rectal bleeding. Use repetition
and paraphrasing to facilitate the interview process.

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Gastrointestinal Examination Practice
In small groups, revise the examination of the gastrointestinal system

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Tutorial 3 – History Taking

This tutorial introduces jaundice, a change in body function that is both a symptom and a sign
of disease. Jaundice, which is also called “icterus”, is a yellow pigmentation of the skin or
sclerae caused by elevated levels of bilirubin in the blood stream.

Most patients do not present by saying that they have jaundice. They are more likely to report
that their eyes have gone yellow or to describe other symptoms associated with the jaundice
or its underlying cause.

Bilirubin metabolism
It is important to have an understanding of the biochemistry and pathophysiology of bilirubin
metabolism when interviewing a patient who has jaundice. Bilirubin is the pigment produced
by metabolism of haemoglobin released during the destruction of red blood cells at the end of
their life span. It circulates in the bloodstream in an unconjugated form bound to albumin.
After being taken up by hepatocytes in the liver, bilirubin is conjugated to bilirubin
glucuronide. This water soluble form of bilirubin is secreted into bile and then into the
intestines. It is then excreted in faeces or metabolised in the presence of bacteria to
urobilinogen, which can be reabsorbed and excreted via the kidneys. You will learn about
this in more detail in your basic science lectures.

Causes of jaundice
There are many causes of jaundice. These can be divided into two major categories:
(i) Disorders causing predominantly unconjugated hyperbilirubinamia:
a. Over-production of bilirubin (pre-hepatic jaundice)
This type of jaundice occurs when there is increased destruction of red blood cells, which is
called haemolysis. The liver cannot process all the excess bilirubin produced. This leads to a
build up of unconjugated bilirubin in the bloodstream. Haemolysis is caused by a range of
diseases including malaria, drug reactions, and genetic diseases such as sickle cell anaemia.

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b. Impaired uptake or conjugation of bilirubin by the liver
Certain medications, such as rifampicin, can interfere with the uptake of bilirubin by the
liver and thus cause jaundice. Abnormalities in conjugation can also cause jaundice.
Gilbert’s syndrome, which is caused by deficiency of glucuronyl transferase, is a common
cause of defective conjugation of bilirubin.

(ii) Disorders causing mixed unconjugated and conjugated hyperbilirubinaemia:

a. Impaired bilirubin secretion into bile cannaliculi
Jaundice can occur when there is defective secretion of bilirubin from the liver into the bile
canniculi. This can be caused by impaired secretion of bilirubin by h e p a t o c y t e s (such as
in the rare familial Dubin-Johnson syndrome) or by destruction of the intra- hepatic bile ducts
by diseases such as primary biliary cirrhosis.

b. Liver disease
Damage to hepatocytes can cause impairment of bilirubin uptake, conjugation and excretion.
Although liver damage produces mixed hyperbilirubinaemia, an increase in conjugated
bilirubin usually predominates as excretion is the rate- determining step. The most common
causes of jaundice due to liver disease are viral and alcoholic hepatitis.

c. Obstruction of the bile ducts (post-hepatic jaundice)

The most common causes of jaundice due to obstruction of the bile ducts are gall stones in the
common bile duct (choledocolithiasis) and cancer of the head of the pancreas. This type of
jaundice leads to an increase of predominantly conjugated bilirubin.

Symptoms associated with jaundice

There are a number of specific symptoms associated with jaundice. These may be the
first symptoms noticed by the patient, rather than the jaundice itself.
(i) Dark urine
Increased excretion of conjugated bilirubin causes dark urine. Unconjugated bilirubin is not
water soluble and therefore is not excreted by the kidneys.
(ii) Pale or clay-coloured stools
Metabolites of bilirubin excreted by the liver into the intestines give faeces their normal
brown colour. When bile duct obstruction occurs, the stools may appear pale or clay-

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coloured due to lack of pigmentation.
(iii) Pruritus
The cause of pruritis (itchy skin) in the setting of jaundice is not known but is thought to be
due to a build up in the skin of bile salts or other substances usually excreted by the biliary
system.

Interviewing a patient about jaundice

When interviewing a patient who presents with jaundice, identify the cardinal features,
although not all will be relevant.

Site, for example, has little significance because hyperbilirubinaemia is a systemic condition.
Jaundice, however, will usually be noticed first in the sclerae as these are rich in elastin, a
tissue with a high affinity for bilirubin. As the level of bilirubin rises, the skin appears
yellow as well. Quality is a cardinal feature that is not particularly helpful.

Determining the severity of jaundice by history alone is often difficult. Jaundice is usually
apparent when the concentration of bilirubin is > 50 µmol/L (normal < 17 µmol/L). Higher
bilirubin levels are usually present when jaundice affects the skin and sclerae rather than the
sclerae in isolation. In severe cases, the skin can appear green due to the oxidation of bilirubin
to biliverdin.

The time course of the jaundice is more likely to contribute useful information. Abrupt onset
suggests acute hepatitis or gall stones whereas insidious onset over weeks to months is more
likely to be due to conditions such as malignancy or chronic cirrhosis. Jaundice that occurs
intermittently points to gall stones in the common bile duct or Gilbert’s syndrome.

The context and precipitating factors of the jaundice are important to elicit. An infectious
cause may need to be considered in a traveller returning from overseas. Mild intermittent
jaundice precipitated by viral illnesses or fasting suggests Gilbert’s syndrome.

Ask about specific symptoms that can occur with jaundice (dark urine, pale stools and itch).
The patient may also volunteer other associated features that are related to the underlying
cause. When you have learned more about diseases that can cause jaundice, you will be able
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to ask questions about risk factors in order to rank the potential diagnoses. You are not
expected to be able to do this at this level of your training.

Case Study 2.05

Kirk Johnson, 26, has developed jaundice

while on a trip to South-East Asia. He is
being inter- viewed by Dr Geeta Srivasta.

Watch the interview and answer the

following questions:

(i) Draw a time line of Kirk’s illness to show how his jaundice relates to the
associated features.

(ii) Explain how Kirk’s symptoms link with the pathophysiology of jaundice.

(iii) Discuss features of his jaundice that might help to differentiate between
potential causes.

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Role play

In pairs, use role play to practise interviewing a patient with jaundice. Afterwards, discuss how
the patients’ symptoms relate to the pathophysiology of jaundice.

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Tutorial 4 – History Taking
During this tutorial, we are going to explore the process of clinical reasoning, using
dysphagia as the prototype symptom.

Clinical reasoning
The formulation of a diagnosis is often one of the key tasks required of a clinician during a
consultation, particularly when the patient is presenting with a new symptom. Sometimes the
features of the presenting problem fit a recognised pattern and a diagnosis can be made quite
readily. More often, the process of making a diagnosis involves gathering information about
the patient’s problem in order to generate a list of diagnostic hypotheses. This list can be
further refined on the basis of the physical examination and relevant investigations. This, in
many ways, is similar to the process that you use during your Problem-Based Learning
(PBL) tutorials.

One approach to making a diagnosis is to find out about every detail of the patient’s history
first and then generate the list of possible causes. This, however, is not a very efficient
method. An experienced clinician will usually start generating hypotheses as he or she
listens to the patient’s opening statement. After the cardinal features of the presenting
problem have been elicited, focussed questions are then asked in order to narrow down the
diagnostic possibilities.

Each symptom has its own particular list of differential diagnoses. Sometimes there can be a
very large number of possibilities so to begin with usually only the common or serious
causes of the symptom are considered. When asking a patient about a symptom, it is usually
helpful to have the potential diagnoses organised into a cognitive framework that reflects the
underlying anatomical or pathophysiological processes. This is preferable to just learning by
rote all the possible causes.

During your medical training, you will build a working knowledge of how to approach each
symptom. You have already had some experience of thinking about how information
obtained in a medical interview can be used to prioritise possible causes, such as finding out
if the symptom is acute or chronic or by considering the temporal profile. You will build on
these skills during this tutorial by learning how to use a structured framework to interview a
patient who has dysphagia as a presenting problem.

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Dysphagia
The word dysphagia is derived from the Greek “dys” (with difficulty) and “phagia” (to eat). It
is used when a patient is having difficulty with swallowing. It specifically refers to the
sensation of having food becoming stuck as it passes through the pharynx or oesophagus. It is
different from odynophagia which means there is pain on swallowing, although often these two
symptoms occur together.

There are two main types of dysphagia. These can usually be distinguished by taking a
careful history:
(i) Oropharyngeal dysphagia
This type of dysphagia is defined as difficulty with initiation of the swallowing process. It is
caused by diseases that affect the pharynx and upper oesophagus, such as stroke, Parkinson’s
disease and multiple sclerosis. Patients with oropharyngeal dysphagia report that food
becomes stuck immediately upon swallowing and may feel the symptom most in the cervical
region. It is often associated with coughing or choking and nasal regurgitation.

(ii) Oesophageal dysphagia

This type of dysphagia arises when the passage of food or liquid through the oesophagus to the
stomach is hindered by a pathological process. Patients with oesophageal dysphagia
report symptoms after initiating a swallow and may localise the symptom to the retrosternal
area. Oesophageal dysphagia can in turn be divided into two types according to the underlying
mechanism:
a. Motility disorder
When the patient has difficulty swallowing both solids and liquids from the onset, the
cause is usually a motility (or neuromuscular) disorder. One example is achalasia, a
disease in which there is loss of peristalsis in the distal oesophagus.

b. Mechanical obstruction
Difficulty swallowing solids only at the onset points to a mechanical obstruction such
as cancer of the oesophagus. Dysphagia for liquids may develop later as the underlying
disease progresses.

It is, of course, important to find out about all of the cardinal features of the presenting
symptom, particularly the time course. Dysphagia that is rapidly progressive over
26  
 
weeks to months raises the possibility of malignancy. Long-standing and intermittent
symptoms, by way of contrast, are more likely to be due to benign conditions such as
oesophageal spasm.

This flow-chart summarises the above information. It can be used as a framework when you
are interviewing a patient who presents with dysphagia. At this stage of your medical career,
you do not need to know about the specific underlying causes.

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Case Study 2.03

Tony Failla, a 56-year old fruiterer, has devel-

oped difficulty with swallowing over the past
two months. He is being interviewed by Nick
Modrze- wski, a first-year medical student.
Watch the interview and write down the cardinal
features of Mr Failla’s presenting symptom.
Apply your clinical reasoning skills by using
the frame- work from the previous page.
Determine the most likely category of his
dysphagia.

Role play
In pairs, use role play to practise your clinical reasoning skills using dysphagia as the
presenting symptom.

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Tutorial 5 – History Taking

During the Introduction to Clinical Medicine program so far, we have focussed on how to
explore a patient’s presenting problem by asking about the cardinal features. A complete
medical interview, however, contains many other important elements. During this tutorial, we
are going to focus our attention on the assessment of a patient’s alcohol intake.

Alcohol in health and disease

Alcohol is widely consumed in our society and plays a central role in many social activities.
It may even confer health benefits when consumed in moderation.

Many people, however, consume alcohol at levels that place them at significant risk of
physical or psychological harm. Alcohol is a contributing factor in many medical conditions,
such as chronic liver disease, heartburn, hypertension and depression. It is also a major cause
of injury due to accidents and is the basis for many social problems, such as absenteeism
from the workplace and disrupted relationships.

It is important to ask all adult and adolescent patients about their alcohol consumption. Do
not assume that a patient does not have a problem with alcohol just because he or she appears
well- presented and is highly functioning.

Assessment of alcohol intake

There are many ways of approaching an alcohol history. A few brief questions may
establish that the patient drinks no alcohol or only a modest amount. A more detailed
history, however, is indicated if there is concern that a patient has a problem with unhealthy
alcohol use.

Alcohol History
Quantitative assessment
Start the alcohol history by asking the patient if they drink alcohol. If the patient states that
they do not currently drink alcohol, ask if they ever have in the past. If they have, it is useful
to explore this further, as past alcohol use may have an impact on their current health.

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If the patient does drink alcohol, establish how often they have a drink containing alcohol.
Then quantify the amount of alcohol they would usually drink on typical day when drinking.
This involves finding out what type of alcohol they are drinking (i.e. beer, wine or spirits)
and how much they are drinking.

Units of alcohol are described as standard drinks. One standard drink contains 10 grams of
alcohol. When quantifying a patient’s alcohol intake, it is useful to express this as a number
of standard drinks. Patients may not always have an accurate idea of how many standard
drinks they are consuming. For example, someone may tell you they have 5 stubbies of full
strength beer a night and they consider this to be 5 drinks, but 5 stubbies of beer actually
equates to 7.5 standard drinks.

Next explore the frequency of heavy drinking by asking how often they would have six or
more standard drinks on one occasion.

The current Australian NHMRC alcohol guidelines state that “the lifetime risk of harm from
drinking alcohol increases with the amount consumed. For healthy men and women, drinking
no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-
related disease or injury.”

Qualitative assessment

Ask about the circumstances in which the patient drinks alcohol. Find out about triggers and
associated psycho-social factors that influence when and how much the patient drinks. Also
find out about any attempts they have made to reduce their alcohol consumption. Ask what
techniques have been used and why these were or were not successful. Include an assessment
of the person’s current motivation to change their drinking behaviour.

If the patient drinks more than the recommended levels of alcohol then it is important to
enquire about features of alcohol dependence. These questions help to explore for impaired
control over drinking. Ask if the patient has ever had difficulty stopping drinking once they
have started. Also ask if they ever need a drink first thing in the morning to help start the day.
Also explore for whether drinking alcohol has resulted in the patient not being able to do
what is normally expected of them e.g. care for children, go to work.

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Next explore for alcohol-related harm. A person may suffer alcohol related harm without
having features of alcohol dependence. Explore for injuries (to themselves or others) or
blackouts that have occurred after drinking alcohol. Also explore whether the they have ever
felt guilty about their drinking behaviour or whether another person (relative, friend, health
professional) has even been concerned about their drinking.

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 32  
 
AUDIT Questionnaire

One useful tool for assessing a patient’s alcohol intake is the Alcohol Use Disorders
Identification Test (AUDIT)4,5 . This questionnaire consists of ten questions. Each item is
scored out of 4, giving a total possible score of 40. The questionnaire is divided into three
sections, which address consumption, dependence and alcohol-related harm. The marks for
each section are subtotalled to provide specific information about the patient’s alcohol intake.

The first three questions are designed to assess the person’s alcohol consumption. These questions
ask about how often the person drinks alcohol, the typical quantity consumed in standard
drinks and the frequency of heavy drinking. The subtotal for this section can indicate
potentially harmful drinking, even if the person scores zero on the subsequent questions.

Dependence on alcohol is probed using questions 4 - 6. Specifically, these questions are used
to find out if the patient has impaired control over his or her drinking, is prioritising drinking
over other activities or needs to drink the morning after a heavy drinking session. The marks
for this section are used to determine if the patient needs more intensive assessment for
alcohol dependence.

The last four questions are designed to explore alcohol-related harm. They are concerned
with the consequences of high-risk or harmful alcohol use, such as blackouts and injury. Any
score on this section apart from zero indicates the need for further assessment.

Administering the AUDIT Questionnaire

The AUDIT questionnaire can be used in an interview format or can be completed by the
patient independently. Although the AUDIT questionnaire is a very reliable and sensitive tool,
one limitation is its length. A modification of the questionnaire, known as AUDIT-C, contains
just the first three questions and can be easily used in routine medical interviews to screen for
heavy alcohol intake. A more detailed assessment can then be undertaken if a problem is
suspected.

While the AUDIT Questionnaire is a useful tool for assessing a patient’s alcohol use, you

33  
 
may notice that it is not routinely applied in the ward setting. However, you should be
familiar with the questions and use these to assess alcohol consumption, dependence and
alcohol-related harm. This will give you valuable information, even if you do not formally
score the questionnaire.

Remember to maintain eye contact as much as possible when you are using the AUDIT
questionnaire to interview a patient. It is also important to be non-judgemental and not look
disapproving of any information that you elicit. Your duty as a health care professional is to
do your best to help the patient who has problems with alcohol use.

Case Study 2.04a

Gary Burton is a 43-year old business-man who has

heartburn. He is being assessed by gastroen-
terologist, Dr Geeta Srivasta. She asks about his
alcohol intake using the AUDIT questionnaire.

Listen to the interview and use the AUDIT ques-

tionnaire to score Mr Burton’s alcohol intake. Dis-
cuss the results with your tutor.

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Case Study 2.04b

Lindsay James, a 22-year old singer, has

come to see her general practitioner, Dr
Tan, for a repeat prescription of the
contraceptive pill.
Nick Modrezwski, a first year medical
student, is learning how to administer the
AUDIT question- naire. Dr Tan has asked
him to use the question- naire to interview
Lindsay about her alcohol intake.
Listen to the interview and use the AUDIT ques
tionnaire to score Lindsay’s alcohol intake. Dis-
cuss the results with your tutor.

Building your communication skills

While many patients will be candid about their alcohol consumption, others will be reluctant
to divulge the full extent of their drinking. Approaching an alcohol history with an empathic
and non- judgemental manner may encourage the patient to be more forthcoming.

The patient may also be more likely to volunteer important or sensitive information if you
use a technique called sign-posting. This involves giving the patient a signal that you are
making a transition from one part of the interview to the next, and then providing a
justification for the questions that you are about to ask. You may also wish to normalise the
process by emphasising that you ask these questions as a routine part of an interview.

Signposting provides structure for both doctor and patient. By articulating where the
interview is heading, a doctor may manage the interview more effectively and reduce
uncertainty for the patient. Sign-posting promotes a more collaborative approach to the
interview process.

35  
 
Dr Geeta Srivasta used sign-posting during her interview with Gary Burton. She signalled a
transition from asking about his heartburn to asking about his alcohol consumption:

DR SRIVASTA: Now, Mr Burton, one of the other factors that can cause heartburn
is alcohol, so I usually ask about this as a routine part of the interview. Could you please
tell me something about your alcohol intake?
MR BURTON: Well, I enjoy the odd drink or three, I must admit …

More about patient confidentiality

While all patients can expect that you will maintain their confidentiality, they may benefit
from extra reassurance before being asked about potentially sensitive issues, such as alcohol
consumption.

In this setting, it is also recommended that, as a medical student, you make clear that the
boundaries of confidentiality include the patient’s treating doctor, who usually will be your
clinical supervisor. Otherwise, you may be placed in the difficult situation of having
responsibility for crucial information about the patient that you have promised not to share.

When interviewing Lindsay James about her alcohol intake, Nick Modrezwski raised the
issue of confidentiality as well as signalling to her that the information obtained would be
shared with his supervisor, Dr Tan:

NICK: … I’m practising using a questionnaire to ask patients about their

alcohol intake because of the effect that it can have on their health. Dr Tan said that you are
happy to do this while you wait to see her.
LINDSAY: Sure. Fire away.
NICK: First, I’d like to emphasise that your answers will remain confidential
with Dr Tan and me.
LINDSAY: OK.

36  
 
Role play
In pairs, use role play to practise interviewing patients about their alcohol use.

37  
 
REFERENCE

1. Introduction to Clinical Medicine 2, Semester 2, Melbourne Medical School, The

University of Melboune, Melbourne.

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