OSCE Checklist for Lower Gastrointestinal Bleeding (LGIB)
หัวข้อการประเมิน / Assessment Topic | รายละเอียด / Details |
การแนะนำและการสื่อสารกับผู้ป่วย / Patient Introduction & Communication | - แนะนำตัวเองกับผู้ป่วยและอธิบายวัตถุประสงค์ของการตรวจ - identity ผู้ป่วย ชื่อสกุล อายุ - ขออนุญาตก่อนทำการตรวจ |
History Taking | - Onset: เริ่มมีอาการเมื่อใด? (Understanding if symptoms started suddenly or gradually helps differentiate acute from chronic conditions. A sudden onset might suggest an acute condition like diverticulitis or a bleeding peptic ulcer, while a gradual onset may indicate colorectal cancer or hemorrhoids.) - Duration: ระยะเวลาที่มีอาการ (Knowing how long the symptoms last can help differentiate between transient and ongoing issues. Short episodes may suggest a self-limited cause, while persistent symptoms might indicate chronic conditions like inflammatory bowel disease or malignancy.) - Frequency: ความถี่ของการมีเลือดออก (Frequent bleeding episodes can indicate a more severe or recurrent condition, such as a bleeding polyp, angiodysplasia, or hemorrhoids.) - Color of Blood: สีของเลือด (สด, สีแดงเข้ม, Maroon stool, สีดำ) (The color helps identify the source of bleeding: bright red blood usually indicates lower GI bleeding, while dark red or maroon stool may suggest a source from the right colon or small intestine. Black stool, or melena, typically indicates upper GI bleeding due to the digestion of blood as it passes through the GI tract.) - Associated Symptoms: มีอาการหน้ามืด, ใจสั่น, เป็นลม หรือไม่? (May suggest significant blood loss or anemia.) - Protrusion During Defecation: เวลาถ่ายมีก้อนยื่นออกมาบริเวณทวารหนักหรือไม่? (คิดถึง Hemorrhoid) - Incomplete Evacuation: มีความรู้สึกว่าถ่ายไม่สุดหรือไม่? (อาจคิดถึง colorectal cancer) - Pain on Defecation: มีอาการแสบหรือเจ็บเวลาถ่ายหรือไม่? (อาจคิดถึง anal fissure) - Abdominal Pain: มีอาการปวดท้องร่วมด้วยหรือไม่? (Pain localized in the lower abdomen can indicate diverticulitis, while diffuse pain might suggest inflammatory bowel disease or ischemic colitis.) - Weight Loss: น้ำหนักลดหรือไม่? (Unintentional weight loss can be a sign of colorectal cancer or chronic illness such as inflammatory bowel disease.) - Jaundice: มีอาการตัวเหลืองตาเหลืองหรือไม่? (อาจบ่งบอกถึงโรคตับ, suggesting liver disease, which may cause easy bleeding.) - Change in Bowel Habits: ท้องผูก, ท้องเสีย, หรือ tenesmus หรือไม่? (Changes like constipation, diarrhea, or tenesmus could suggest colorectal cancer or IBD.) - Alcohol Use: ดื่มสุราเป็นประจำหรือไม่? (Alcohol use can indicate liver disease, such as cirrhosis, which can lead to coagulopathy and increased risk of bleeding.) - Liver Disease: มีประวัติโรคตับหรือไม่? (เช่น cirrhosis, hepatitis, conditions that might cause coagulopathy and gastrointestinal bleeding.) - Blood Disorders: มีประวัติโรคเลือดหรือไม่? (เช่น coagulopathy, hemophilia, which can cause spontaneous bleeding or exacerbate GI bleeding.) - Family History: ประวัติมะเร็งลำไส้ใหญ่ในครอบครัว (Family history can indicate a genetic predisposition to colorectal cancer or other hereditary GI conditions.) - Past Medical History: ประวัติการตรวจส่องกล้องลำไส้ใหญ่ (Colonoscopy), เอกซเรย์สวนแป้งแบเรียม (Barium enema) (These procedures can provide a history of previous findings that might be relevant.) - Medication History: Use of NSAIDs, steroids, warfarin (NSAIDs and steroids can cause or exacerbate GI bleeding; warfarin indicates anticoagulation, which increases bleeding risk.) - Allergies: ประวัติการแพ้ยา (Important to know for planning future management and treatment.) |
Physical Examination | - General Appearance: ดูสภาพทั่วไปของผู้ป่วย (ดูว่า patient มีอาการตัวเหลืองตาเหลือง (jaundice) หรือไม่, good conscious, well cooperative หรือไม่, และมี cyanosis หรือ clubbing หรือไม่) - Vital Signs: วัดความดันโลหิต, ชีพจร, อุณหภูมิ, อัตราการหายใจ (Vital signs help assess hemodynamic stability and may indicate significant blood loss if abnormal.) - Abdominal Examination: Inspect for any distension or visible masses. Auscultate for bowel sounds to assess for bowel obstruction or ileus. Palpate for tenderness (คิดถึง peritonitis, diverticulitis), masses (คิดถึง malignancy), and organomegaly. Percuss for any dullness which may suggest ascites or mass. - Rectal Examination: ตรวจหาติ่งเนื้อ ริดสีดวงทวาร, แผลปริแตก, ก้อนเนื้อ, ตรวจหาความตึงตัวของกล้ามเนื้อทวารหนัก (พบก้อนคิดถึง hemorrhoid, anal fissure, mass) |
Digital Rectal Examination (DRE) | 1) แจ้งกับผู้ป่วยว่าจะขอตรวจทวารหนัก ขอความร่วมมือ ให้บุคคลที่สามมาอยู่ด้วยเวลาตรวจ 2) เตรียมอุปกรณ์: ถุงมือสะอาด, lubricant, ไฟฉาย, กระดาษชำระ 3) จัดท่าผู้ป่วย: ให้นอนตะแคงไปทางด้านซ้าย, งอเข่า 2 ข้าง, ก้มคางชิดอก 4) สวมถุงมือสะอาดที่ lubricated, บอกว่าจะตรวจ อาจจะรู้สึกไม่สบายได้ ไม่ต้องเกร็ง หมอจะทำเบาๆ 5) ดูจากข้างนอกเข้าใน: มองหา external hemorrhoids, skin tags, rectal prolapse, anal fissure, fistula in ano, warts, abscess, sign of inflammation 6) ให้ผู้ป่วยลองเบ่งทวารหนัก: ดู rectal prolapse, prolapsed internal hemorrhoids 7) Test the anal wink: ใช้สำลีสะกิดบริเวณรอบ anus จะเห็น brisk anal contraction หากผิดปกติบ่งบอกถึง fecal incontinence มีปัญหาใน spinal cord 8) คลำไล่จาก buttock เข้ามา: ดูมี tender fluctuation ตรงไหนหรือไม่ เข้ามาถึง perianal area โดยวางปลายนิ้วชี้บริเวณรอบๆ anus เบาๆ บอกผู้ป่วยให้ relax ค่อยๆสอดนิ้วชี้เข้าไปในทวารหนัก แค่ข้อนิ้วเดียว 9) ตรวจดู sphincter tone ขณะผู้ป่วยยังไม่เบ่ง (resting tone): ตรวจ internal anal sphincter ต่อมาให้ผู้ป่วยขมิบเพื่อตรวจ external anal sphincter tone 10) สอดนิ้วเข้าไปให้สุดแล้วหมุนนิ้วตรวจดูให้ทั่วทุกด้านของทวารหนัก: ดู smooth rectal surface ไหม, พบ nodule, irregularities, induration 11) ตรวจผนังด้านหน้าของทวารหนัก: ในผู้ชาย ตรวจ prostate glands บอกผู้ป่วยว่าอาจรู้สึกอยากปัสสาวะได้ (Prostate gland มี 2 lobes มี cleft อยู่ตรงกลาง ตรวจขนาด, nodule, symmetry, consistency, tenderness) 12) ในผู้หญิง ตรวจ cervix: ดูว่ามี bulging, tender หรือไม่ 13) ถอยนิ้วออกเบาๆ: สังเกตุดูสีอุจจาระที่ติดมา (แดง เหลือง น้ำตาล melena maroon หรือซีด), อุจจาระแข็งหรือนิ่ม มีมูกเลือดปนหรือไม่ 14) เช็ดทวารหนักให้ผู้ป่วยด้วยกระดาษชำระ 15) เสร็จการตรวจแล้วให้ผู้ป่วยแต่งตัว แพทย์บันทึกผล และแจ้งผลให้ผู้ป่วยทราบ |
Differential Diagnosis | - Conditions to consider: Hemorrhoids, anal fissures, diverticulitis, colorectal cancer, angiodysplasia, NSAID-induced colitis, IBD, peptic ulcer - พิจารณาวินิจฉัยแยกโรคตามอาการและประวัติที่ได้รับ (Link symptoms and history to specific conditions, e.g., weight loss with colorectal cancer, jaundice with liver disease.) |
Diagnostic Investigations | - Laboratory tests: CBC (ประเมินภาวะโลหิตจางและความผิดปกติของเม็ดเลือด), Coagulation profile (ประเมินความผิดปกติในการแข็งตัวของเลือด), LFTs (ตรวจดูการทำงานของตับ) (Laboratory tests help evaluate for anemia, coagulopathy, or liver dysfunction.) - Imaging: Colonoscopy (ส่องกล้องเพื่อประเมินหาสาเหตุการมีเลือดออก), CT Angiography (สำหรับผู้ป่วยที่มี active bleeding), Technetium-99m scan (for suspected Meckel’s diverticulum) - Barium Enema: เอกซเรย์สวนแป้งแบเรียม ใช้ในการวินิจฉัยโรคของลำไส้ใหญ่ (such as polyps, tumors, or diverticular disease) - การตรวจเพิ่มเติมด้วยการส่องกล้อง การตรวจภาพ และการตรวจเลือดตามความเหมาะสม (Imaging helps localize bleeding, diagnose lesions, and assess for underlying conditions.) |
Management Plan | - Initial management: Resuscitation, stabilize vital signs (ควบคุมอาการและรักษาสัญญาณชีพให้คงที่) - Definitive management: Endoscopic hemostasis (หยุดเลือดโดยการส่องกล้อง), surgical intervention (ผ่าตัด), medical management based on the underlying cause (การรักษาตามสาเหตุที่พบ) (Management strategies are guided by the underlying cause of bleeding and the patient's clinical status.) - Colonoscopy after bleeding is stopped: LGIH bleeding is stopped. Don't forget to do Colonoscopy for diagnosis and treatment. |
Patient Education and Follow-up | - อธิบายผลการตรวจและการวินิจฉัย - ให้คำแนะนำเกี่ยวกับการรักษาและวิธีการดูแลตนเองที่บ้าน - กำหนดการติดตามผลหลังการรักษา (Ensuring the patient understands their condition, the planned management, and the importance of follow-up is crucial for successful outcomes.) |
Explanation for OSCE Checklist for Lower Gastrointestinal Bleeding (LGIB)
History Taking:
Onset: Understanding when the symptoms began is crucial in differentiating between acute and chronic conditions. For example, a sudden onset of bleeding might suggest an acute process such as diverticulitis, a bleeding peptic ulcer, or an upper GI bleed if melena is present. In contrast, a gradual onset might indicate a more chronic issue such as colorectal cancer or hemorrhoids, which are associated with ongoing or intermittent bleeding.
Duration: The length of time the symptoms have been present can help differentiate between self-limited and ongoing conditions. Short episodes of bleeding might suggest a self-limited cause, such as an isolated episode of diverticular bleeding or a small anal fissure. In contrast, persistent or recurrent symptoms could indicate a chronic condition such as inflammatory bowel disease, angiodysplasia, or malignancy. Understanding the duration helps in assessing the severity and urgency of the condition.
Frequency: The frequency of bleeding episodes provides insight into the severity and potential complications of the condition. Frequent bleeding can indicate a severe or recurrent condition, such as a bleeding polyp, ongoing inflammation in IBD, or repeated episodes of diverticulitis. High-frequency bleeding can also lead to complications like anemia, requiring a more urgent and comprehensive approach to management.
Color of Blood: The color of the blood is a key factor in localizing the source of the bleeding. Bright red blood (hematochezia) usually indicates lower GI bleeding, often from sources such as hemorrhoids, anal fissures, or diverticular disease. Dark red or maroon stool suggests bleeding from the right colon or small intestine, while black stool (melena) indicates upper GI bleeding, likely from the stomach or duodenum, where blood is digested as it passes through the gastrointestinal tract. Differentiating these sources is crucial for guiding diagnostic and therapeutic strategies.
Associated Symptoms: Symptoms such as dizziness, palpitations, or syncope may suggest significant blood loss or anemia. These symptoms indicate the need for urgent intervention and may guide the decision to perform resuscitation measures or transfusions. They also suggest a more severe pathology that may require endoscopic or surgical intervention.
Protrusion During Defecation: The presence of a protruding mass during defecation suggests hemorrhoids or a rectal prolapse. This symptom is important for diagnosing anorectal conditions and deciding whether conservative management (such as dietary changes and topical treatments) or surgical intervention is necessary.
Incomplete Evacuation: The sensation of incomplete evacuation can be a sign of colorectal cancer, particularly if associated with a change in bowel habits or weight loss. It can also be seen in rectal masses or strictures, which may cause a mechanical obstruction to stool passage. This symptom prompts further investigation with imaging and possibly endoscopy to rule out malignancy.
Pain on Defecation: Pain during defecation is typically associated with anal conditions such as anal fissures or hemorrhoids. It can also be seen in inflammatory conditions such as proctitis. Understanding the nature and location of the pain can help differentiate these conditions and guide appropriate management.
Abdominal Pain: Abdominal pain, particularly if localized to the lower abdomen, can indicate diverticulitis or colitis. Diffuse abdominal pain might suggest inflammatory bowel disease, ischemic colitis, or other diffuse inflammatory processes. Pain characteristics, including onset, duration, and aggravating factors, are critical for guiding diagnostic evaluation and management.
Weight Loss: Unintentional weight loss can be a sign of colorectal cancer or a chronic inflammatory condition such as Crohn's disease or ulcerative colitis. It indicates a more systemic or serious underlying pathology that warrants a thorough workup, including imaging and endoscopic evaluations.
Jaundice: The presence of jaundice suggests liver disease, which can cause coagulopathy and increase the risk of bleeding. Jaundice may also indicate a hepatobiliary source of bleeding or metastatic disease. It requires further investigation with liver function tests and imaging to determine the cause and guide management.
Change in Bowel Habits and Tenesmus: Changes in bowel habits, such as constipation, diarrhea, or tenesmus (a feeling of incomplete evacuation), can suggest colorectal cancer or inflammatory bowel disease. These symptoms warrant further evaluation with colonoscopy and biopsy to diagnose the underlying condition and plan appropriate treatment.
Alcohol Use: A history of alcohol use can suggest liver disease, such as cirrhosis, which may lead to portal hypertension and variceal bleeding or coagulopathy and increased risk of bleeding from other sources. This information is essential for assessing the patient's bleeding risk and planning management strategies.
Liver Disease: A history of liver disease, such as cirrhosis or hepatitis, can indicate coagulopathy and increased bleeding risk. Liver disease can also cause portal hypertension and variceal bleeding, which require specific management strategies, including endoscopic banding and medical therapy to reduce portal pressure.
Blood Disorders: A history of blood disorders, such as coagulopathy or hemophilia, increases the risk of spontaneous bleeding or exacerbation of existing bleeding. This information is crucial for assessing bleeding risk, planning perioperative management, and considering the need for factor replacement or other hematologic support.
Family History: A family history of colorectal cancer or other hereditary gastrointestinal conditions, such as Lynch syndrome or familial adenomatous polyposis, increases the patient's risk of developing these conditions. This information guides the decision for earlier and more frequent screening, including colonoscopy and genetic counseling.
Past Medical History: A history of previous colonoscopy or barium enema can provide important information about past findings, such as polyps or diverticular disease, which may impact the current presentation. This information helps in formulating a differential diagnosis and guiding further evaluation and management.
Medication History: The use of NSAIDs, steroids, or anticoagulants like warfarin can increase the risk of gastrointestinal bleeding. NSAIDs can cause mucosal injury and ulcers, steroids may exacerbate bleeding by thinning the mucosal lining, and anticoagulants increase bleeding risk. Understanding medication history is crucial for assessing bleeding risk, planning endoscopic or surgical interventions, and deciding on the need for medication adjustments or reversal.
Allergies: Knowing the patient's allergies is important for planning future management and treatment, especially when considering medications for bleeding control, anesthesia, or contrast agents for imaging.
Physical Examination:
General Appearance: Assessing the general appearance of the patient can provide immediate clues about the severity of their condition. Observing signs like jaundice may indicate liver disease, while pallor could suggest anemia from chronic or severe acute blood loss. The patient's overall consciousness and cooperation levels can also provide insight into their hemodynamic stability and mental status, guiding further urgent assessment and management.
Vital Signs: Vital signs, including blood pressure, heart rate, temperature, and respiratory rate, are essential for assessing hemodynamic stability and identifying signs of shock or sepsis. Hypotension and tachycardia can indicate significant blood loss and the need for urgent fluid resuscitation or blood transfusion. Fever may suggest an underlying infection, such as diverticulitis or colitis, requiring antibiotic therapy.
Abdominal Examination: A thorough abdominal examination involves inspection, auscultation, palpation, and percussion. This systematic approach helps identify signs of peritonitis, such as tenderness or guarding, which may indicate diverticulitis or perforation. Distension could suggest bowel obstruction, while organomegaly might indicate hepatic or splenic involvement. Palpating for masses can help identify malignancies or inflammatory conditions, and percussion can help assess for ascites or intra-abdominal masses.
Rectal Examination: A rectal examination is crucial for identifying anorectal conditions such as hemorrhoids, anal fissures, rectal prolapse, or masses. This examination can also help assess sphincter tone, which may be affected by neurological conditions. Findings on rectal examination guide the need for further diagnostic testing, such as colonoscopy, and help determine appropriate management strategies, including surgical intervention.
Digital Rectal Examination (DRE):
Preparation and Communication: Proper preparation and communication with the patient are essential for conducting a thorough and respectful DRE. Explaining the procedure, obtaining consent, and ensuring a third party is present for patient comfort and medico-legal protection are critical steps. Proper positioning of the patient ensures an adequate examination while maintaining patient dignity.
Inspection and Palpation: Inspecting the external anal area and perianal skin helps identify conditions like hemorrhoids, skin tags, fissures, fistulas, warts, or abscesses. These findings can help localize the source of bleeding and determine the need for further interventions. Palpating the anal canal and rectal walls allows for the assessment of sphincter tone and the identification of masses, tenderness, or other abnormalities.
Sphincter Tone and Anal Wink Test: Assessing sphincter tone, both at rest and during voluntary contraction, helps evaluate the function of the internal and external anal sphincters. The anal wink test assesses the integrity of the sacral reflex arc and can indicate neurological issues if abnormal. These assessments are crucial for diagnosing conditions like fecal incontinence or spinal cord injuries.
Prostate and Cervix Examination: In male patients, palpating the prostate gland through the anterior rectal wall assesses for size, consistency, and tenderness, which can indicate benign prostatic hyperplasia, prostatitis, or prostate cancer. In female patients, examining the cervix helps assess for tenderness or bulging, which may suggest gynecological issues contributing to the patient's symptoms.
Documentation and Post-Examination Care: After completing the examination, documenting findings accurately and informing the patient of the results is essential for ongoing care. Proper communication of findings ensures the patient understands their condition and the next steps in their management plan.
Differential Diagnosis:
Creating a differential diagnosis involves linking the patient's symptoms and history to potential conditions. For example, a patient presenting with bright red blood per rectum and a history of hemorrhoids likely has bleeding hemorrhoids, while a patient with weight loss, changes in bowel habits, and iron deficiency anemia should be evaluated for colorectal cancer. A comprehensive differential diagnosis considers common and rare causes of lower GI bleeding, guiding appropriate investigations and management.
Diagnostic Investigations:
Laboratory Tests: Complete blood count (CBC) helps assess for anemia, which may indicate chronic blood loss or acute significant bleeding. A coagulation profile evaluates for coagulopathies that might exacerbate bleeding, while liver function tests (LFTs) assess for underlying liver disease, which could cause or contribute to bleeding.
Imaging: Imaging studies, such as colonoscopy, CT angiography, and Technetium-99m scans, are essential for localizing the source of bleeding, diagnosing lesions, and assessing for underlying conditions. Colonoscopy is particularly useful for direct visualization of the colon and rectum, allowing for biopsy and therapeutic interventions. Barium enema can help identify structural abnormalities, such as polyps, tumors, or diverticular disease, especially when colonoscopy is not feasible or informative.
Colonoscopy After Bleeding Stops: Even if the bleeding has stopped, a colonoscopy is often indicated to identify the source of bleeding and prevent recurrence. It provides definitive diagnosis and allows for therapeutic interventions, such as polyp removal or hemostasis of bleeding lesions.
Management Plan:
Initial Management: The initial management focuses on resuscitation and stabilizing the patient’s vital signs. This includes fluid resuscitation, blood transfusions if necessary, and addressing any coagulopathy. Stabilizing the patient is critical to prevent further complications and prepare for definitive management.
Definitive Management: Definitive management is based on the underlying cause of bleeding. Endoscopic hemostasis is often the first-line treatment for actively bleeding lesions, providing both diagnostic and therapeutic benefits. Surgical intervention may be necessary for patients with refractory bleeding, large tumors, or complications like perforation or ischemia. Medical management, including proton pump inhibitors, antibiotics, or specific therapies for underlying conditions (e.g., corticosteroids for IBD), is tailored to the patient’s specific diagnosis.
Colonoscopy After Bleeding Stops: A colonoscopy should be performed after the bleeding has stopped to identify the source of the bleeding and provide definitive treatment. It allows for direct visualization, biopsy, and therapeutic interventions such as polypectomy, banding of hemorrhoids, or coagulation of bleeding vessels.
Patient Education and Follow-up:
Educating the patient about their diagnosis, treatment plan, and follow-up care is crucial for successful outcomes. This includes explaining the findings, the rationale for recommended treatments, and the importance of adherence to the management plan. Follow-up appointments are essential to monitor for recurrence, manage ongoing conditions, and provide additional treatments if necessary. Proper patient education ensures that patients are engaged in their care and understand the steps they need to take to manage their health effectively.
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