Digital Rectal Exam Ailbe - PowerPoint Presentation

Slide1

Digital Rectal Exam

Ailbe

Slide2

Third year advice

Try and clerk as many patients as you can

Practice on friends

Be able to interpret ECGs, CXRs and ABGs

Be competent at taking

blood

, doing

cannulas

and doing

sutures

(These usually come up in OSCEs)

Know how to explain procedures and concepts to patients

Don’t worry about trying to know everything for the

writtens

– Learn whatever Amir Sam and Prof

Meeran

teach you and then top up your knowledge with whatever you’ve learnt from firms + your favourite resources (Mine is BMJ best practice)

Slide3

Indications for DRE

Rectal bleeding

Urinary symptoms

Constipation

Rectal pain (probably would just do inspection rather than a full DRE)

Faecal incontinence

(Urinary incontinence)

Slide4

Introduction

Introduce yourself

Confirm the patient’s details

Explain the examination

Consent

CHAPERONE (required)

Slide5

History

Will need to be very focused in an OSCE setting

Find out the presenting complaint

Slide6

History

Urinary symptoms

FUNDHIPS

Slide7

History

Bowel symptoms

Rectal bleeding

Tenesmus

Perianal itching

Pain on defecation

FLAWS

Smoking and alcohol history

Slide8

History

ICE

Slide9

Examination – Equipment and Preparation

Wash hands

Gather gloves, apron, lubricant and paper towels

Explain to the patient that they need to be exposed from waist down and lying on their left side

Give patient privacy while they prepare

When patient is ready, ask them to bring their knees to their chest

Slide10

Examination – Inspection

As always, do inspection around the bed and general inspection of the patient

Do a closer inspection of the peri-anal area and anus

Slide11

Examination – Inspection

Haemorrhoids

Image from nhs.uk

Slide12

Examination – Inspection

Fissures –

Looks like a cut on the anus

Fistulae –

Connected to an adjacent lesion near the anus

Abscesses –

Might see pus leakage

Prolapse –

May appear as a pink mass protruding from the rectum

Slide13

Examination – Palpation

Tell the patient that you’re about to begin

Place finger on coccyx momentarily before beginning

Enter rectum and palpate anteriorly for the prostate

Rotate your finger (wrist) 360 degrees and feel the rectal walls for haemorrhoids and masses

Assess anal tone by asking the patient to squeeze your finger

Withdraw finger and inspect for blood, stool and mucus

Slide14

Examination – Wrapping up

Gently wipe off any lubricant from the patient and hand them paper towels so they can wipe themselves if needed

Allow the patient to sort themselves and get dressed in private

Dispose of clinical waste

Wash hands

(!)

Slide15

Investigations (Bowel)

Full abdominal examination

Bloods

FBC and inflammatory markers

U&Es

LFTs

Bone profile

Stool sample

FOBT

Faecal calprotectin

Slide16

Investigations (Bowel) – Continued

Abdominal x-ray (Not particularly useful)

Flexible sigmoidoscopy/colonoscopy with biopsy

CT colonography for bowel cancer

(Tumour markers such as CEA/CA19-9 for colon cancer)

Slide17

Investigations (Prostate)

Urinalysis

MC&S

Blood

Bloods

FBC and inflammatory markers

U&Es

LFTs

Bone profile

PSA

USS of urinary tract for hydronephrosis

Transrectal ultrasound guided needle biopsy of prostate if indicated

Slide18

Investigations (Prostate) – Continued

International Prostate Symptom score

Bother score

Volume charting

Slide19

Differentials

Underlined

differentials are ones that may be found on DRE

Slide20

Differentials

Rectal bleeding

Haemorrhoids

Anal fissures

Colorectal cancer

Diverticulitis

IBD (Crohn’s may cause fistulae and abscesses)

Rectal varices due to portosystemic anastomosis (RARE)

Slide21

Differentials

Obstructive urinary symptoms

BPH

Prostate cancer

Prostatitis

(tends to present more like a UTI)

Irritative urinary symptoms

Prostatitis

(tends to present more like a UTI)

UTI

Bladder cancer

Slide22

Differentials

Constipation

IBS

Medications

Lack of dietary fibre

Bowel obstruction e.g. due to

colorectal cancer

Slide23

Differentials

Faecal incontinence

Neurological pathology

– MS, Stroke

Structural damage to anus

e.g. following surgery

Diarrhoea

Age associated

Slide24

Extras

I haven’t covered management in this lecture

I would recommend roughly learning management for haemorrhoids, BPH and prostate cancer, but this is mainly for the

writtens

, as management doesn’t come up often in OSCEs (this is more of a PACES thing)

Learn cancer screening pathways for colon cancer, breast cancer and cervical cancer (unrelated to DRE, but they come up in

writtens

every now and then)

Slide25

Cancer screening

Bowel

60-74 every 2 years with FOBT

Endoscopy at 55 years old

Breast

47-73 every 3 years with a mammogram

Cervical

24-49 every 3 years

50-64 every 5 years

With cervical smear

If you suspect cancer, put on

2 week wait referral

Slide26

Thanks for listening

Email: as11015@ic.ac.uk