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MBChB – CURRICULUMMBChB – CURRICULUM

Clinical MethodsClinical MethodsSemester 6Semester 6

GastroenterologyGastroenterology

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DOCTORDOCTORWhat is IBS?What is IBS?

Do I haveDo I havecancer?cancer?

I can't lead I can't lead a normal lifea normal life

I have thisI have this pain in my pain in my abdomenabdomen

Where is Where is the toilet?the toilet?

Can it be Can it be treated?treated?

Patient’s concerns

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PsychologicalPsychologicalcomorbiditycomorbidity

SeriousSeriousdiseasedisease

Hidden agendaHidden agendanarcotics,laxatives,narcotics,laxatives,

benefitsbenefits

Shall I refer?Shall I refer?RecentRecent

stressful eventstressful event

Impaired Impaired daily daily

functionfunctionDrossman Drossman et alet al, 1995; 1997, 1995; 1997

Doctor’s concerns

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History takingHistory taking

A: PRINCIPLE PROBLEMA: PRINCIPLE PROBLEMB: SYSTEMIC ENQUERYB: SYSTEMIC ENQUERY

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History takingHistory taking

± 80 %± 80 % of diagnosis can be made by of diagnosis can be made by proper history taking proper history taking

Put patient at ease – patients always Put patient at ease – patients always afraid of doctors afraid of doctors

Acquire patient’s trustAcquire patient’s trust

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A: MAIN COMPLAINTA: MAIN COMPLAINT

1. Mouth 2. Problems with swallowing3. Nausea4. Vomiting5. Eating habits6. Weight7. Heartburn8. Gaseousness, bloating & flatulence9. Abdominal pain10. Bowel habits

10.1 10.1 Diarrhoea10.2 10.2 Constipation

11. Jaundice

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1. Mouth1. Mouth

Mouth soresMouth sores Breath Breath Tongue & tasteTongue & taste Teeth & gumsTeeth & gums ThroatThroat

Back to MAIN COMPLAINTMENU

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2. Problems with swallowing2. Problems with swallowing Dysphagia – difficulty with swallowing Aphagia – no water or solids can be Aphagia – no water or solids can be

swallowed (emergency for swallowed (emergency for obstruction)obstruction)

Odynophagia – painfull swallowingOdynophagia – painfull swallowing Globus pharyngeous (hystericus) – Globus pharyngeous (hystericus) –

lump lodged in the throat feelinglump lodged in the throat feeling Phagophobia – fear of swallowingPhagophobia – fear of swallowing Infections – immune status Infections – immune status

dysphagia & odynophagiadysphagia & odynophagiaBack to MAIN COMPLAINTMENU

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2.1 Dyphagia2.1 Dyphagia(difficulty with swallowing(difficulty with swallowing))

Water or solidsWater or solids Acute or chronic presentation Acute or chronic presentation Where does food get stuckWhere does food get stuck Nasal regurgitationNasal regurgitation Simultaneous symptoms Simultaneous symptoms

Chest pain, hoarseness, weight lossChest pain, hoarseness, weight loss Hiccup – level of diaphragmHiccup – level of diaphragm

2. Problems with swallowing2. Problems with swallowing

Back to problems withSwallowing menu

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3. Nausea3. Nausea Nausea in relation with mealsNausea in relation with meals Nausea for specific foods – Nausea for specific foods – fatty meals – gall fatty meals – gall

stonesstones

With emotional stressWith emotional stress Time – morning sickness Time – morning sickness

pregnancypregnancy raised intracranial pressureraised intracranial pressure

DrugsDrugs FeverFever

Back to MAIN COMPLAINTMENU

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4. Vomiting4. Vomiting Vomiting with or without nauseaVomiting with or without nausea Projectile vomiting Projectile vomiting ((raised intracranial pressureraised intracranial pressure)) In relation with mealsIn relation with meals With emotional stressWith emotional stress DrugsDrugs FeverFever Simultaneous bowel motions – none or DiarrhoeaSimultaneous bowel motions – none or Diarrhoea What does the patient vomit:What does the patient vomit:

undigested foodundigested food blood (hematemesis or black coffee grounds)blood (hematemesis or black coffee grounds) bilebile

Back to MAIN COMPLAINTMENU

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5. Eating habits5. Eating habits Appetite increase or decreasedAppetite increase or decreased

6. Weight6. Weight Gain or lossGain or loss Loss on purpose or spontaneousLoss on purpose or spontaneous Loss gradually or recentlyLoss gradually or recently

Back to MAIN COMPLAINTMENU

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7. Heartburn7. Heartburn

WhenWhen With or after mealsWith or after meals EveningsEvenings Whole dayWhole day How oftenHow often

Alarm signsAlarm signs dysphagiadysphagia coughing spells especially at nightcoughing spells especially at night weight lossweight loss

Back to MAIN COMPLAINTMENU

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8. Gaseousness, bloating & 8. Gaseousness, bloating & flatulence flatulence

AerophagiaAerophagia(swallowing of air)(swallowing of air)

Belching (vomiting of air) & FlatulenceBelching (vomiting of air) & FlatulenceAbdominal distentionAbdominal distention

Back to MAIN COMPLAINTMENU

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9. Abdominal pains9. Abdominal pains

Associated with:Associated with: MealsMeals Bloating and bowel distentionBloating and bowel distention Specific abdominal areaSpecific abdominal area Cramps / deep painCramps / deep pain Constant or intermittendConstant or intermittend Improve with passing of stoolsImprove with passing of stools

Back to MAIN COMPLAINTMENU

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10. Bowel habits10. Bowel habits

What is your normal bowel habitWhat is your normal bowel habit

Recent change in bowel habitRecent change in bowel habit

Back to MAIN COMPLAINTMENU

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10.1 Diarrhoea10.1 Diarrhoea Acute of chronic presentation (>4 weeks)Acute of chronic presentation (>4 weeks) Volume and frequency Day / night rhythmDay / night rhythm ContentContent Colour, odour, consistencyColour, odour, consistency Tenesmus and pain (anus)Tenesmus and pain (anus) Drugs (antibiotics en laxatives)Drugs (antibiotics en laxatives) Sexual activities (AIDS)Sexual activities (AIDS) Travelers DiarrhoeaTravelers Diarrhoea Weight lossWeight loss Previous surgeryPrevious surgery Back to MAIN COMPLAINT

MENU

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10.1 Diarrhoea10.1 Diarrhoea

Volume and frequencyVolume and frequency High volume, low frequency – small bowelHigh volume, low frequency – small bowel Low volume, high frequency - colonLow volume, high frequency - colon

Day / Night rhythmDay / Night rhythm Only during daytime – irritable bowelOnly during daytime – irritable bowel Only at night (early morning) – diabetic Only at night (early morning) – diabetic

autonomic neuropathyautonomic neuropathy

Back to diarrhoea Main menu

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10.1 Diarrhoea10.1 Diarrhoea

ContentContent waterwater mucusmucus blood (hematochezia or black melena)blood (hematochezia or black melena) Food residue (undigested)Food residue (undigested) Float on water (fat malabsorptionFloat on water (fat malabsorption))

Back to diarrhoea Main menu

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10.1 Diarrhoea10.1 Diarrhoea

Weight lossWeight loss diabetes mellitusdiabetes mellitus malignancymalignancy psychiatricpsychiatric hyperthyroidismhyperthyroidism malabsorptionmalabsorption TBTB AIDSAIDS

Back to diarrhoea Main menu

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10.1 Diarrhoea10.1 Diarrhoea

Previous surgeryPrevious surgery subtotal gastrectomysubtotal gastrectomy short bowel syndromeshort bowel syndrome afferent loop syndromeafferent loop syndrome Ileum-resectionIleum-resection post cholecystectomy post cholecystectomy

syndrome (bile acids)syndrome (bile acids)

Back to diarrhoea Main menu

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10.2 Constipation10.2 Constipation Individual variation according to eating Individual variation according to eating

habitshabits

Acute or chronic presentationAcute or chronic presentation

Frequency – how many times per weekFrequency – how many times per week

Abdominal distentionAbdominal distention

Pain – improvement after passing of stoolsPain – improvement after passing of stools

Bloating and flatulenceBloating and flatulence

Consistency – hard pellet stoolsConsistency – hard pellet stools Straining (25 %)Straining (25 %)

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10.2 Constipation (continue)10.2 Constipation (continue) Feeling of incomplete evacuationFeeling of incomplete evacuation Blood per rectum – after, around or in the Blood per rectum – after, around or in the

stools – red (hematochazea) or black melena stools – red (hematochazea) or black melena stoolsstools

DrugsDrugs Emosional statusEmosional status Weight lossWeight loss Previous surgeryPrevious surgery Other diseases – Diabetes Mellitus, Other diseases – Diabetes Mellitus,

HypothyroidismHypothyroidism Back to MAIN COMPLAINTMENU

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11. Jaundice11. Jaundice

Family history – Hepatitis BFamily history – Hepatitis B Occupation – doctors and laboratory Occupation – doctors and laboratory

personnelpersonnel Transfusions and injections – Transfusions and injections – Hepatitis B en CHepatitis B en C Tattoos and skin ringsTattoos and skin rings Alcohol useAlcohol use Travel history – Hepatitis Travel history – Hepatitis OperationsOperations Sexual orientation – Hepatitis B en CSexual orientation – Hepatitis B en C MedicationMedication

B: Systemic enquiry

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History takingHistory taking

A: MAIN COMPLAINTA: MAIN COMPLAINTB: SYSTEMIC ENQUERYB: SYSTEMIC ENQUERY

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B: SYSTEMIC ENQUERYB: SYSTEMIC ENQUERY

1.1. All other systemsAll other systems

2.2. Previous diseasesPrevious diseases

3.3. Previous operationsPrevious operations

4.4. Current medicationCurrent medication

5.5. OccupationsOccupations

6.6. Socio-economicSocio-economic and habitsand habits

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