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Chronic upper abdominal symptoms

Clinical Discipline(s)/Organ System(s)
Digestive System, General Practice, Gastroenterology & Hepatology, Infectious Diseases, General Surgery
Progress Test Topic(s)
A 33 year old NZ European woman presents to her GP with fatigue, dyspepsia and acid reflux. Her symptoms have been slowly developing over the past couple of months. You take a history and examine her. After presenting your findings to the GP they ask you how you would like to manage her symptoms.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Anatomy of the gastrointestinal tract
   - Physiology of acid production in the stomach, function of the lower oesophageal sphincter and gallbladder
   - Iron, vitamin B12 and folate absorption
   - Pathophysiology of gallbladder disease, hiatus hernia
   - Genetic predisposition to gastric cancer
   - Progression of malignancy from pre-cancerous to cancerous to metastatic disease
   - Histopathology of oesophagitis, peptic ulcers and gastric cancer
   - Microbiological characteristics of Helicobacter pylori; diagnosis and treatment
   - Pharmacology of non-steroidal anti-inflammatory drugs, antacids, proton pump inhibitors, H2 antagonists, metoclopramide, oral bisphosphonates
Clinical and Communication Skills 
   - Outline the dietary control advice in gastro-oesophageal reflux disease
   - History from the patient with fatigue (including possible psychological component, stress); recognise red flag symptoms
   - History from a patient with reflux, dyspepsia; recognise red flag symptoms
   - Perform an examination of the abdomen
   - Differential diagnosis of chronic upper abdominal symptoms
   - Indications for endoscopy, biopsy, abdominal ultrasound; complications of endoscopy
   - Interpret FBC, vitamin B12/ (B12 NZF link)levels,  folate levels , autoantibodies, Schillings test, urea breath testing, liver function tests
   - Recognise the morphological types of anaemia: microcytic, macrocytic, and normocytic
   - Management of H. pylori infection, peptic ulcer disease, dyspepsia, chronic abdominal pain, coeliac disease, pernicious anaemia
   - Risk factors for peptic ulcer disease, including alcohol history
   - Role of psychosocial assessment
   - Appropriate communication for discussing lifestyle including alcohol and weight loss
   - Structuring, framing and timing of consultation
Personal and Professional Skills 
   - Demonstrate an empathic approach to a patient with chronic symptoms
   - Time-management: taking a complex history in a primary care setting
   - Awareness of own relationship with alcohol
Hauora Māori 
   - Appropriate engagement and consultation with whānau
   - Cater for differential health literacy needs of Māori patients and whānau
   - Consideration of patient and whānau needs with regards to ‘breaking bad news
   - Consideration of access to cultural/spiritual support for patient and whānau
Population Health 
   - Economic and social impacts of fatigue
   - Epidemiology of H. pylori: prevalence, associations, treatment
   - Epidemiology of dyspepsia, pernicious anaemia, gastric cancer, gastro-oesophageal reflux disease
Conditions to be considered relating to this scenario
peptic ulcer disease, gastro-oesophageal reflux disease, H. pylori infection, non-steroidal anti-inflammatory drug use, gastritis, coeliac disease, irritable bowel syndrome, gallstones, pregnancy, pernicious anaemia
Less common but 'important not to miss'
ovarian carcinoma, gastric cancer, gastrointestinal lymphoma, pancreatitis
Zollinger-Ellison syndrome