GI + Renal OSCE

AMSA Edinburgh x IMU Y4

Introduction to OSCE
 OUR TEAM

GOH YOU
UoE Y4 medical student
IMU ME218

CHUA SHUEN JIN

UoE Y4 medical student
IMU ME118
 1
History Taking
History Taking Components

● Introduction, confirm patient, consent

● Presenting complaint
● HOPI
● Systemic review
● Past medical history
● Drug history
● Family history
● Social history
● ICE
Abdominal Pain
 3, 6, 9 Rule

Radiographs

Coffee bean sign

Small bowel obstruction Large bowel obstruction Sigmoid volvulus

GI Bleed
Upper- Haematemesis

● Variceal or non-variceal?
○ Variceal bleed: Terlipressin, prophylactic antibiotics
○ Non-variceal bleed: Urgent endoscopy (clipping), PPI/H2RA once confirmed
● Blatchford score (1st assessment), Rockall score (after endoscopy)
● Medical emergency!

Lower- Blood in stools

● From upper or lower GIT?

○ Site, amount, trigger
● Red flag symptoms: dysphagia, unexplained anaemia, weight loss, anorexia, age >55,
jaundice
 *Don’t forget thyroid
disease can also cause
Change in Bowel Habit change in bowel habit

Inflammatory bowel -Chronic diarrhoea, blood & mucus, lower Colonoscopy with biopsy, faecal -Lifestyle advice, vaccination
disease abdominal pain calprotectin (IBD vs IBS), OGD -CD: glucocorticoids
-A/W aphthous ulcers, anal skin tags, (UC vs CD) -UC: aminosalicylates
osteoporosis

Irritable bowel -Young woman, stressed Associated mental health issues Lifestyle & dietary advice (low
syndrome ->6 months of ABC: abdominal pain, bloating, FODMAP diet)
change in bowel habit

Coeliac disease -Change in bowel habit, steatorrhoea,
abdominal pain, bloating
-A/W unexplained iron/vit B12/folate
deficiency, dermatitis herpetiformis,
hyposplenism
Total IgA & IgA anti-TTG Lifelong gluten free diet, dietician,
(*ensure >6 weeks of gluten annual bloods, vaccination
diet), endoscopic intestinal
biopsy (histology)

Diverticular disease -Intermittent LLQ pain, change in bowel habit, CT colonography Analgesia, follow ups
rectal bleeding, bloating, mucus in stool

Colorectal CA -Red flags: rectal bleeding, abdominal mass, PR exam, colonoscopy with 2-week urgent referral pathway,
change in bowel habit >6 weeks, weight loss biopsy, CT colonography, CT MDT, surgery/radio/chemoTx,
CAP (metastasis) palliative Tx
*Bowel CA screening in Scotland
 ● Pruritus, stools, urine
● Red flags: Confusion, haematemesis, fever,
Jaundice purpura, painless jaundice,
Kayser-Fleischer ring
weight loss
Hyperpigmentation (HH)
(Wilson’s disease)

Pre-hepatic -Unconj. bilirubin ↑ Haemolysis Haemolytic anaemia, hypersplenism

-No pale
stools/dark urine Other Gilbert’s syndrome (recent viral illness), malaria (fever,
travel Hx)

Intrahepatic -Unconj. & conj. Hepatitis Viral, alcoholic, drug-induced, autoimmune

bilirubin ↑
-± Pale stools & Cancer Hepatocellular: 2° to chronic hepatitis B/C, metastatic
dark urine
Other Wilson’s disease, hereditary haemochromatosis

Post-hepatic -Conj. bilirubin ↑ Pancreatic CA Painless jaundice

-Pale stools & dark
urine Gallstones 6Fs: Female, forties, fat, fertile, family Hx, fair

Other 1° biliary cirrhosis, 1° sclerosing cholangitis

Systemic Review
● Systemic: fevers, weight change, fatigue, early satiety

● Cardiovascular: chest pain, oedema, syncope, palpitations

● Respiratory: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain

● Genitourinary: oliguria, polyuria, dysuria, urinary frequency

● Neurological: visual changes, motor or sensory disturbances, headache, confusion

● Musculoskeletal: chest wall pain, trauma

● Dermatological: rashes, pruritus, skin lesions, jaundice

● Endocrine: thyroid symptoms

Dermatitis herpetiformis in Coeliac disease

Past Medical History

Adhesions post surgery- major

cause of small bowel obstruction
Drug History
● Regular medications, OTC medications, herbal medicines, supplements
● Allergies, triggers (gluten?)

● NSAIDS, aspirin- GI bleed

● St John’s Wort- enzyme inducer
● Contraception- chance of being pregnant?
● Opiates- constipation (prophylactic laxatives), nausea (prophylactic antiemetics)

Family History
● Familial adenomatous polyposis, Lynch syndrome (HNPCC), colorectal CA, Coeliac
disease, IBD
Social History

● Smoking/ever smoked before, quantify

● Alcohol (UK limit: 14 units/week): ? CAGE questionnaire
● Recreational drugs
● Diet
● Exercise
● Occupation
● ? Travel Hx
● ? Sexual Hx
Ideas, Concerns, Expectations

● Very important!
● “How has this been affecting your day to day life?”

● “Do you have any idea yourself what might be causing this?”
● “Do you have anything you are particularly worried that this might be?”
● “What were you hoping I’d be able to do for you today?”
 Reporting History Findings

● SBAR
● DDx (2-3)
● I would like to…
○ Perform an abdominal examination
○ Do bedside observations (NEWS shart, Bristol stool chart)
○ Order blood tests (FBC, U&Es, LFTs, clotting, CRP, blood culture, serum amylase, group
and save, cross-match, bone profile, anti-TTG, tumour markers etc)
○ Order further Ix (Stool culture, faecal occult blood test, faecal calprotectin, pregnancy
test, abdominal X ray, erect chest X ray, OGD/colonoscopy, biopsy, abdominal CT, USG
Pneumoperitoneum
abdomen, MRCP etc)
○ Suggest Tx/Mx (refer to gastroenterology/surgery, laparoscopic cholecystectomy, ERCP,
MDT: dietician/SALT, major haemorrhage protocol, triple therapy, lifestyle modifications,
support groups)
*Ix: From bedside, from non-invasive
: confirm Dx, exclude DDx, look for underlying cause, look for Cx, Mx purposes
 Possible OSCE Stations

1 HT: Dyspepsia
-GORD?
3 Explanation:
Colonoscopy procedure
5 Explanation & Mx:
Coeliac disease
-Know H. Pylori Mx
-Don’t forget anxiety -Before, during, after -”Not a food allergy or a
food intolerance, it is an
autoimmune disease”

2 PE: GI exam
-Most likely findings:
4 A-E assessment:
GI bleed
-Gluten: barley, wheat, rye

pain/organomegaly/
ascites- give DDx -Blood on the floor and 4 more
-Activate major haemorrhage
protocol, group and save, cross-match
Sample Cases
● A-E assessment: Drowsiness, lightheadedness, palpitations, abdominal pain (not
mentioned)
○ GI bleed

● Hx & empathy: Upper GI discomfort (3-4 weeks central sharp pain, worse lying flat,
currently stressed at work, PMH low mood & anxiety)
○ GORD/anxiety

● PE: Lightheadedness and black stools for past 3 days, taking ibuprofen for knee
pain
○ Peptic ulcer

● Interpretation & HT: Lethargy, dizziness, weight loss, given blood results
(electrolytes, LFTs, TFTs)- hypoNa, hyperK, borderline hypoCa, high PTH, normal T4
○ Primary adrenal insufficiency (Addisons disease)
UoE Mark Scheme
 2
Physical Examination
Components of PE
1. Introduction
2. General Inspection
3. Hands, Arms, Face, Neck, Torso, Legs
4. Abdomen
a. Inspect
b. Palpate - Superficial, Deep, Liver, Spleen, Kidney
c. Percuss
d. Auscultate
5. Thank patient +/- Explain to patient
6. Report PE findings +/- Answer examiner questions [Last 2 minutes]
Introduction
WIIPPE
1. Wash hands + PPE

2. Introduce yourself
“Hi, I’m ______, a fourth year medical student from the University of Edinburgh.”

3. Identity - Patient’s name + DOB / Age

4. Permission - Explanation of procedure + Consent

“I heard you came in with (chief complaint). Would it be okay for me to examine you
today? This would involve me having look and feel around your hands, face and
tummy. ”

5. Position
Ensure patient is comfortable and supine, with head only on 1 or 2 pillows.

6. Exposure
Expose tummy from xiphisternum to symphysis pubis.

- Chaperone, if appropriate.
General Inspection
Before starting, ask - if patient is in any pain
- if patient needs to use the washroom

1. Inspect patient’s general condition.

- Is the patient alert, conscious, responsive?
- Is the patient in pain?
- Is the patient in respiratory distress? Is patient on oxygen?
- Skin colour - Pallor? Jaundice? Hyperpigmentation?
- Nutritional state/body habitus - cachectic? Obese?
- Any smell? - Fetor hepaticus /
- Mobility aids?

2. Inspect surrounding for any medical equipment.

- Any NEWS/fluid/medication charts?
- Any medication around? Eg. Creon bottles
- Any medical devices attached? Eg. NG tube, oxygen mask, stoma bags
- Any NBM signs?
 Hands
Things to look for:

Palms: Nails:

Dupuytren Koilonychia
Contracture IDA - Crohn’s/ Coeliac
? excess alcohol use
Leukonychia
Palmar erythema Hypoalbuminemia - CLD
CLD/pregnancy/hyperthyroidism
Clubbing
CLD, IBD, Coeliac, Lymphoma
Pallor of GI tract

?Underlying anemia
 Hands
Things to do:

Nails: Palm:
1. CRT <2sec 1. Temperature
2. Clubbing 2. Dupuytren’s
(Schamroth window contracture
test)

Wrist:
1. Radial pulse - Rate, Rhythm, Volume
2. Asterixis/Flapping tremor
(Hepatic encephalopathy/ Uraemia from renal
failure / Type 2 respi failure)
 Eyes:
1. Conjunctival pallor
Arms, Face, Neck 2.
(Anaemia)
Icteric sclera (Jaundice)
3. Corneal arcus
4. Xanthelasma
(Hyperlipidaemia - NAFLD/
Axilla: cholestasis - PBC)
1. Hair loss 5. Kayser-Fleischer rings
(IDA & malnutrition) (Wilson’s disease)
2. Acanthosis nigricans 6. Uveitis (IBD)
(Can be normal or assc w T2DM
or GI malignancy)
Mouth::
1. Glossitis (IDA, B12 & folate deficiency)
2. Angular stomatitis “
Arms: 3. Oral candidiasis (immunosuppressed)
1. Bruising (Liver failure) 4. Aphthous ulcers (IBD)
2. Scratch marks 5. Hyperpigmented freckles
(Cholestatic liver disease)
(Peutz-Jeghers syndrome)
3. Needle Track Marks
(Hepatitis) Neck:
4. Mention BP 1. Palpate LN
(Virchow - L supraclavicular
LN - Commonly gastric ca)
Chest, Legs
Legs:
1. Erythema
Chest: nodosum (IBD)
1. Spider naevi (>5)
2. Gynaecomastia
3. Hair loss 2. Pyoderma
(Signs of increased estrogen - gangrenosum
Liver cirrhosis) (IBD)

3. Pitting oedema
(Hypoalbuminemia -
Liver cirrhosis)
 Abdomen - Inspection
Inspect patient’s abdomen for:
1. Scars
2. Stomas (Site, contents of bag, spouted/flush with skin)
3. Striae (Cushing, EDS, obesity, pregnancy)
4. Sinuses & fistulas
5. Distension (5Fs - fat, fluid, flatus, faeces, fetus)
6. Caput medusae (portal HTN)
7. Hernias
8. Movement with respiration (absent in peritonitis)
9. Peristaltic bowel movements (bowel obstruction)
10. Cullen’s/ Grey-Turner’s sign (late sign in acute pancreatitis)

RIF- ileostomy

Transverse -
Loop
Colostomy

LIF - colostomy
 Abdomen - Palpation & Percussion
- Ensure hands are warm.
- Kneel if bed is low.
- Ask pt if any pain & point to where pain is
maximal.
- Watch patient’s face while palpating.

1. Palpate Abdomen
a. Superficial
b. Deep
Report on - Tenderness.
Masses.
Guarding.

If relevant - Rovsing’s sign (appendicitis)

- McBurney’s sign

2. Percuss over 4 quadrants

- Normal: Dull over fluid/solid organs (liver,
spleen), tympanic over rest
- Percussion tenderness = peritoneal irritation
Abdomen - Palpation
 Abdomen - Palpation & Percussion
2. Palpate for liver
- Start @ RIF, use radial side of right index finger
- Instruct pt to breathe in and out deeply (tip: breathe with pt)
- Press in before inspiration. Move superiorly towards RUQ on Percuss
expiration
- Perform Murphy’s sign for cholecystitis. Instruct pt to take deep
breath while your fingers @ right costal margin.
- Normal: Liver edge smooth and palpable 2cm below costal
margin
- Not normal:
>2cm (Hepatomegaly)
Nodular (cirrhosis)
Tender (Hepatitis or cholecystitis)
Pulsatile (Tricuspid regurgitation)

3. Percuss for liver

- Start @ RIF, percuss up to find lower border of liver when note
turns dull Palpate & Percuss
- Percuss downwards along R MCL to find upper border of liver
(normally beneath 5th rib).
- Normal: liver span 6 - 12 cm
 Abdomen - Palpation & Percussion
4. Palpate for spleen
- Same as liver; Start @ RIF, use radial side of right index finger
- Instruct pt to breathe in and out again
- Press in before inspiration. Move diagonally towards LUQ on
expiration
- Feel along left costal margin
- Normal: Not palpable, can only be felt if increased in size
threefold.

5. Percuss for spleen (If spleen was palpable)

- To confirm findings from palpation
- Start @ RIF, percuss diagonally towards LUQ till note changes
from resonant to dull
- Normal: spleen should not be identifiable with percussion

Palpate +/- Percuss

 Abdomen - Renal
6. Bladder
i. Bladder palpation
- Before palpating the bladder, check if pt needs to use the toilet
- Inform pt that it may be uncomfortable and they might have the urge
to pass urine.
- Normal: bladder not palpable
- Palpable bladder in suprapubic region: urinary obstruction/retention
Percuss

ii. Bladder percussion

- Percuss downwards midline from umbilical towards pubic symphysis
- Dullness to percussion indicates upper border of the distended
bladder
 Abdomen - Renal
7. Kidneys
i. Ballot the kidneys
- On each flank, place left hand behind the pt’s
back, beneath the lowest rib and right hand
anteriorly above.
- Firmly, push hands together as pt breathes out.
- Ask pt to take a deep breath in.
- Feel for lower pole of kidney moving down
between hands.
- If palpable, push kidney back and forth to
demonstrate mobility to confirm kidney. Assess
its size, surface and consistency.

ii. Renal punch

- Have patient sit up
- Warn pt that they might experience discomfort
- Identify renal angle (12th rib and spine)
- Firmly tap the renal angle with ulnar side of fist
and note any discomfort
- Tenderness: usually pyelonephritis
 Abdomen - Ascites
8. Test for ascites
i. Shifting dullness
- Percuss from umbilicus to left flank laterally.
- If ascites present, note will turn dull.
- If dull, keep finger in position and, ask pt to roll
towards you. Percuss
- Hold for 30 seconds.
- Repeat percussion.
- If resonant, ascites present.

ii. Fluid thrills

- Have pt place ulnar edge of hand vertically and
firmly at umbilicus
- Flick finger at right of abdomen while feeling for

Pt’s hand
a ripple against the palm on the left side.
 Abdomen - Auscultation
9. Auscultate for bowel sounds
- Put diaphragm of stethoscope to the right of
umbilicus
- If no sounds after 2 mins -> auscultate all four
quadrants
- Normal: Low pitch gurgling sounds every 5-10 sec
- Absent bowel sounds: Paralytic ileus or peritonitis
- Increased, high-pitched tinkling bowel sound:
Intestinal obstruction

10. Bruits
Place diaphragm
- Above umbilicus: abdominal aorta bruit (AAA)
- 2-3 cm above and lateral to umbilicus: renal artery
bruit (RAS)
Reporting PE Findings
1. Today, I examine [Patient’s name], a [age]-[gender].
2. On general inspection …
3. Peripherally …
4. On inspection of the abdomen …
5. On superficial/deep palpation…
6. Percussion was …
7. Bowel sounds were … and bruits were …
8. In summary, these findings were consistent with a normal abdominal examination/
disease.
9. To complete my examination, I would perform a full set of bloods (FBC, U&E, LFT), a
digital rectal exam (PR), check hernial orifices and examine external genitalia.

Questions:
1. Differential diagnosis +/- Why?
2. Specific investigations
3. Management plan
UoE Mark Scheme
 3
Practice History Taking
RESOURCES
● The Easy Guide to Focused History Taking for OSCEs (McCollum)
● Geeky Medics
● Zero to Finals
● Macleod's Clinical Examination
● OSCE Cases with Mark Schemes
● Essential Examination
● OSCEstop
● PassMedicine
Feedback Time :)