A

Fig. 6.30 Computed tomogram of the pelvis. A, Diverticular abscess.

OSCE example 1: Abdominal pain and diarrhoea

Mr Reid, 29 years old, presents with a 6-month history of anorexia, 7 kg weight loss, abdominal pains and diarrhoea (liquid stool). He underwent

appendicectomy 4 months ago following severe right iliac fossa pain.

Please examine the gastrointestinal system

• Introduce yourself and clean your hands.

• Start with a general inspection: body habitus, signs of dehydration, fever and pallor.

• Inspect the hands: palmar erythema, finger clubbing, leuconychia, koilonychia, nicotine stains and swollen finger or wrist joints.

• Inspect the face: signs of anaemia (pallor, angular stomatitis), swollen lips and aphthous mouth ulcers.

• Inspect the skin: erythema nodosum or pyoderma gangrenosum.

• Inspect the abdomen: laparotomy scars or skin fistulae.

• Palpate for right iliac fossa tenderness or the presence of a firm, non-tender mass.

• Offer to examine the perianal area for the presence of dusky blue discoloration, oedematous skin tags and the presence of fissures, fistulae or

ulcerations.

• Thank the patient and clean your hands.

Summarise your findings

This 29-year-old man with a history of weight loss and diarrhoea appears comfortable at rest but looks thin. He has a recently healed appendicectomy

scar, mild periumbilical and left iliac fossa tenderness, and normal bowel sounds.

Suggest a differential diagnosis

The differential diagnosis is Crohn’s disease and irritable bowel syndrome.

Suggest initial investigations

Full blood count, C-reactive protein, liver function tests, urea, creatinine and electrolytes, iron studies, vitamin B12 and folate levels, ileocolonoscopy and

small bowel magnetic resonance imaging, faecal calprotectin.

Investigations • 117

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OSCE example 2: Jaundice

Mr MacDonald, a 61-year-old retired salesman, presents with increasing tiredness and loss of appetite over 4 months. Two weeks ago he noticed dark

urine and pale stools, and his friends have remarked that his eyes have become yellow. He has drunk a litre of whisky a day for the last 5 years,

although recently he has cut down to a bottle of whisky every 3 days.

Please examine this patient’s abdomen

• Introduce yourself and clean your hands.

• Unless prompted otherwise, proceed to peripheral examination prior to concentrating on the abdomen.

• Carry out a general inspection: body habitus, evidence of malnutrition, pallor or jaundice, scratch marks on the forearm and back, bruising.

• Examine the hands: palmar erythema, finger clubbing, leuconychia, Dupuytren’s contractures.

• Check for flapping tremor.

• Examine the face: telangiectasias, xanthelasmas, bilateral parotid enlargement and jaundice (yellow sclera of the eyes and skin).

• Smell for alcohol or fetor hepaticus.

• Inspect the neck and chest for spider naevi, gynaecomastia; look for axillary and chest hair loss.

• Inspect the abdomen for distension, everted umbilicus, caput medusae or scars of recent drain insertion.

• Palpate and percuss the abdomen for hepatomegaly and splenomegaly.

• Percuss for shifting dullness.

• Auscultate for hepatic bruits.

• Look for peripheral oedema.

• Thank the patient and your clean hands.

Summarise your findings

This patient is jaundiced with multiple spider naevi on the chest and abdomen. He has generalised abdominal swelling with shifting dullness and a firm

liver edge palpable 2 cm below the costal margin.

Suggest a differential diagnosis

The differential diagnosis is alcoholic cirrhosis, chronic hepatitis and hepatoma.

Suggested initial investigations

Liver function tests, ferritin, viral hepatitis screen, full blood count and prothrombin time, urea, creatinine and electrolytes, alpha-fetoprotein, abdominal

ultrasound scan and upper digestive endoscopy (to check for oesophagogastric varices).

Integrated examination sequence for the gastrointestinal system

• Position the patient: supine and comfortable on the examination couch. Expose the abdomen from the xiphisternum to the pubic symphysis.

• Inspection: start with general observation, then inspect the skin, face, neck and chest, and finally the abdomen.

• Palpation:

• Begin with light, superficial palpation away from any site of pain, then repeat with deeper palpation.

• Describe any mass and decide whether there is an enlarged abdominal organ.

• Palpation for hepatomegaly:

• Ask the patient to breathe in deeply through the mouth and feel for descent of the liver edge on inspiration.

• Move your hand progressively up the abdomen, between each breath, until you reach the costal margin or detect the liver edge.

• Percussion to confirm hepatomegaly:

• Ask the patient to hold their breath in full expiration.

• Percuss for liver dullness and measure the distance in centimetres below the costal margin.

• Palpation and percussion for splenomegaly:

• Start with your hand over the umbilicus, moving diagonally up and left to feel for the splenic edge as it descends and moves towards the midline

on inspiration.

• Check for ascites (shifting dullness):

• Percuss from the midline out to the flanks for dullness.

• Keep your finger on the site of dullness in the flank; ask the patient to turn on to their opposite side and then percuss again. If the area of

dullness is now resonant, shifting dullness is present.

• Check for a fluid thrill:

• Place the palm of your left hand flat against the left side of the patient’s abdomen and flick a finger of your right hand against the right side of

the abdomen. If you still feel a ripple against your left hand, a fluid thrill is present.

• Auscultation:

• Listen to the right of the umbilicus for bowel sounds, above the umbilicus over the aorta for arterial bruits, lateral to the umbilicus for bruits from

renal artery stenosis, and over the liver for hepatic bruits.

• Check for peripheral oedema.

• Consider a rectal examination (always with a chaperone).

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