Summary of Common Conditions Seen in OSCEs

Hints and Tips for the Exam

Remember the ‘5 Fs and 1 T’ of Abdominal Distension (Figure 31.1)

• Fat (hypothyroidism, Cushing’s disease)
  
• Fluid (is this ascites?)
  
• Faeces (constipation, obstruction – is it complete?)
  
• Flatus (complete obstruction, food intolerance, irritable bowel syndrome)
  
• Fetus (pregnancy test)
  
• Tumour

Figure 31.1 Abdominal distension

Women’s Health

The sex of the patient will help rule out a number of pathologies that only affect women. If your patient is female, remember to ask about her last menstrual period and the likelihood that she is pregnant. When discussing management with the examiner, remember in your list of investigations to mention offering a pregnancy test. All women of child-bearing age with abdominal symptoms should be offered a pregnancy test. This should also be done before any radiological investigations such as an abdominal X-ray.

Elderly + Bloating = High Possibility of Malignancy

An elderly patient should make you consider malignant processes first and aim to rule these in or out. Both colorectal and ovarian pathology can cause bloating – although constipation is quite often the underlying cause.

Acute Causes

One of the aims in your history will be to assess the urgency of the situation. Is the patient in urinary retention? Does the patient have a toxic dilatation of the colon (megacolon) or are they just constipated? Know the ‘red flag’ signs for acute abdominal conditions.

The chronology of the symptoms is important, so make sure you are comfortable in terms of which came first (e.g. vomiting shortly after eating – high gastrointestinal obstruction; vomiting some time after eating – small bowel obstruction; constipation followed by vomiting (bilious and later faeculant) – lower gastrointestinal obstruction).

An important question commonly forgotten is to ask when the patient last opened their bowels and also if there has been a change. Be sure also to differentiate simple constipation from absolute constipation by asking whether, in addition to not passing stool, they have passed any wind. If not, this may suggest complete obstruction.

Differentiating Between Small Bowel and Large Bowel Obstruction on Abdominal X-Ray

• Small bowel:
  
  
  
  • Prominent loops of bowel in the centre of the abdomen
    
  • Valvulae conniventes that cross the entire width of the small bowel
    
  • No gas in the large bowel
  
  
• Large bowel:
  
  
  
  • Prominent bowel in the periphery of abdomen
    
  • Haustra do not cross the entire width of the bowel
    
  • There is no air distal to the obstruction
  
  
• Remember to look for loops of bowel in the hernial orifices.

Ascites – Transudates Versus Exudates

Abdominal distension caused by fluid has a broad differential diagnosis. Fluid may collect in the peritoneal cavity or in the bowel (e.g. third-space losses as a result of obstruction or ileus). Hence the patient may have symptoms of dehydration such as a dry mouth, thirst and light-headedness. Distension may be a sign of fluid overload so be sure to ask about swelling of the ankles, orthopnoea and paroxysmal nocturnal dyspnoea.

Ascites is the term used to describe fluid in the abdominal peritoneal cavity. The most common cause is cirrhosis of the liver. When discussing the causes in your OSCE, subdivide them into transudative and exudative causes (see the table). The key investigation here is an ascitic tap/drain. This is both diagnostic (as it should be sent for microscopy, culture, sensitivity and cytology) and therapeutic (by offloading fluid to reduce discomfort).

In conjunction with ascites, a fever may signify spontaneous bacterial peritonitis (diagnosed by finding >250/mm³ neutrophils). This is an emergency and requires antibiotic therapy.

Splenomegaly and Hepatomegaly

See Chapter 3 (abdominal examination).

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