Makindo Medical Notes

🩺 OSCE Station – Dyspepsia

Candidate Instructions 📋

You are a final-year medical student in the GP surgery. A 48-year-old patient presents with indigestion. Take a focused history, screen for red flags, discuss differentials, and outline initial investigations and management. You do not need to perform an examination. You have 8 minutes.

Key OSCE Learning Points 🔑

• Dyspepsia = epigastric discomfort/pain, fullness, bloating, or nausea related to the upper GI tract.
• Always screen for alarm features (weight loss, vomiting, anaemia, dysphagia, haematemesis) ⚠️.
• Most cases are benign (functional dyspepsia, reflux, H. pylori) but must not miss gastric cancer.

History to Cover 📝

• Presenting symptoms: epigastric pain, heartburn, bloating, early satiety, nausea, vomiting.
• Character: relation to meals, nocturnal symptoms, effect of alcohol/spicy foods/NSAIDs.
• Red flag symptoms:
  • Dysphagia.
  • Unexplained weight loss.
  • Persistent vomiting.
  • GI bleeding (melaena/haematemesis).
  • Iron deficiency anaemia.
• Medication history: NSAIDs, aspirin, bisphosphonates, steroids.
• Past/family history: peptic ulcer, gastric cancer, liver disease.
• Social history: alcohol, smoking, stress, diet, occupation.

Examiner Prompts 👩‍⚕️

• Epigastric discomfort for 3 months, worse after meals.
• No dysphagia, haematemesis, or melaena.
• Normal appetite, no weight loss.
• Occasional NSAID use for knee pain.
• No family history of gastric cancer.

Differential Diagnosis ⚖️

• Functional dyspepsia (most common).
• GORD (gastro-oesophageal reflux disease).
• Peptic ulcer disease (gastric or duodenal, esp. with NSAIDs/H. pylori).
• Gastric cancer (red flag features).
• Biliary disease (gallstones, cholecystitis).
• Pancreatic disease (pancreatitis, carcinoma).

Investigations 🔬

• Initial (primary care):
  • H. pylori test (urea breath test, stool antigen, or rapid urease test if endoscopy planned).
  • FBC (exclude anaemia), U&E, LFTs.
• Indications for urgent endoscopy (2-week wait):
  • Age ≥ 55 with unexplained dyspepsia + weight loss.
  • Any age with dysphagia, upper GI bleeding, persistent vomiting, iron deficiency anaemia, or epigastric mass.
• Secondary care: Upper GI endoscopy if alarm symptoms or failed empirical treatment.

Management 🚑 (NICE CG184 Dyspepsia & GORD)

• Lifestyle advice: weight loss, smoking cessation, reduce alcohol, avoid late meals, reduce caffeine/spicy/fatty foods.
• Stop offending drugs: NSAIDs, aspirin, steroids where possible.
• Test & Treat H. pylori: Offer eradication therapy (PPI + 2 antibiotics for 7 days).
• Empirical therapy: Trial of full-dose PPI for 4 weeks if no H. pylori or after eradication.
• Non-responders: Consider referral for endoscopy, alternative therapy (H2 blocker, alginates), or specialist review.

Examiner’s Marking Guide 📋

• Introduces self, gains consent, clarifies dyspepsia definition.
• Explores red flag symptoms.
• Asks about NSAID use, alcohol, smoking, family history.
• Suggests H. pylori testing, PPI trial, lifestyle advice.
• Mentions urgent endoscopy if alarm features.

🧑‍⚕️ Case Examples — Dyspepsia

• Case 1 (Functional dyspepsia): 🥴 A 29-year-old woman reports 3 months of upper abdominal discomfort, bloating, and early satiety. She has no red-flag symptoms and normal FBC/LFTs. Diagnosis: Functional (non-ulcer) dyspepsia. Teaching point: Commonest cause of chronic dyspepsia; managed with reassurance, PPI trial, H. pylori testing, and lifestyle advice.
• Case 2 (Peptic ulcer disease): 🩺 A 55-year-old man presents with burning epigastric pain worse at night, relieved by eating. He takes ibuprofen for back pain. Endoscopy reveals a duodenal ulcer. Diagnosis: NSAID-related peptic ulcer disease. Teaching point: Always check drug history (NSAIDs, aspirin); manage with H. pylori eradication and PPI therapy.
• Case 3 (Gastro-oesophageal reflux disease — GORD): 🔥 A 40-year-old woman describes retrosternal burning and regurgitation, worse after meals and when lying flat. Endoscopy is normal. Diagnosis: GORD presenting with reflux-type dyspepsia. Teaching point: Clinical diagnosis; trial of PPI is first-line, with lifestyle modification (weight loss, avoiding late meals).
• Case 4 (Gastric cancer): 🎗️ A 70-year-old man complains of dyspepsia, anorexia, early satiety, and 6 kg unintentional weight loss. He has iron-deficiency anaemia. Endoscopy shows an ulcerating gastric mass. Diagnosis: Gastric carcinoma. Teaching point: Red-flag features (age >55, anaemia, weight loss) → urgent OGD (2-week wait) to exclude malignancy.
• Case 5 (Gallstones / Biliary colic): 💎 A 46-year-old woman presents with episodic right upper quadrant pain radiating to the back,