Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year 2 Doctor working in General Practice. Your next patient is Richard Graham – a 46-year-old male presenting with abdominal pain. Please take a history and perform a relevant examination.
Patient History:
You started to experience pain 2 weeks ago, and it has gradually worsened. You experience a sharp pain affecting the upper regions of your tummy (left + right + central). It comes suddenly on + off. You rate the pain as 6/10. It usually comes on when you eat any food. Pain does not radiate.
You have lost your appetite because of the pain and have been eating less than usual. You have lost some weight – you think this is because you have been eating less than usual but are unsure how much you have lost. You are always tired – you often sleep all day and do nothing significant.
No fever/dysphagia/ jaundice/ vomiting/ acid regurgitation/ early satiety/ bloating/diarrhoea/ nocturnal cough/ hoarse voice
Only mention if asked specifically: You have noticed tarry looking black stool after going to the toilet. No fresh blood can be seen.
Ideas, Concerns, Expectations:
You think it may be cancer because your father had colorectal cancer – you remember your dad had similar symptoms in the past. You are very worried that you have cancer. You don't know how to cope and are very scared of surgery. However, you want to find out what exactly is happening and seek as many treatment options as possible. Ask the doctor if this is cancer.
Past Medical History:
Arthritis + diabetes (do not know which one for both)
Drug History:
Metformin + ibuprofen (for joint pain)
NKDA
Family History:
Father has colorectal cancer, mum has both osteoarthritis and rheumatoid arthritis
Social History:
Ex-smoker – used to smoke ten cigarettes daily for ten years
Drinking three cans of lager daily
Part-time car mechanic
Live with your wife, who looks after you, but you are fully independent at home.
You currently also have three children who live nearby.
Examination Findings:
Central cyanosis/ pale conjunctiva
Tenderness in the epigastric region
PR may show melena
Differentials:
Peptic Ulcer Disease (melena, abdominal pain pattern, NSAID use)
GORD (abdominal pain + SH)
To rule out Upper GI Cancer (melena, weight loss + FH)
Biliary Colic (abdominal pain following eating)
Investigations:
Bedside:
PR examination, if not yet done
Observations
H pylori testing: Urea breath test, stool antigen test
Calculator Blatchford risk score
Bloods:
FBC – due to upper GI bleeding
U&E (baseline)
LFT (rule out liver pathology)
Iron Studies (due to bleeding)
Coagulation Screen (due to bleeding)
Group + Save +/- Cross-match
Imaging/Special Test:
Consider CT if the diagnosis is uncertain/uncontrolled bleeding (malignancy, ischaemia, diverticulitis...etc.)
Endoscopy +/- rapid urease test (CLO test) +/- biopsy to rule cancer
Oesophageal manometry + ambulatory PH monitoring (GORD)
Management: