Reset 10 mins Pause Candidate instructionsActor instructionsMark sheet Score Please examine this patient’s abdomen. Present your findings to the examiner as you go. The examiner will stop you after 6 minutes to ask you to summarise and ask you some questions. You are a 44 year old patient who has come to an outpatient clinic. The consultant as asked if you are happy for a medical student to examine you. Please do not ask any questions or chat to the candidate. Please feel free to stop the examination if the student causes any pain or discomfort to yourself. When the candidate looks at your eyes: show the candidate the following photo (click image): When the candidate looks in your mouth: show the candidate the following photo (click image): When the candidate looks at your abdomen: show the candidate the following photo photo (click image): When they percuss your abdomen: tell the percussion note is dull in the flanks; if they examine for shifting dullness correctly, tell them this is present Category Question Done Excellent Introduction Candidate appropriately introduced themselves with: Full name Role Checks patient’s name and DOB Asks patient for preferred name Étique Examination étique Washes hands Asks about any pain Exposes patient correctly Patient positioned laying flat Examination from right hand side Treats patient with dignity and respect Inspection General inspection General appearance Well / unwell Comfortable / in discomfort Looks around bed Hands Hands Flapping tremor (asterixis) Nails (leukonychia, koilonychia, clubbing) Palms (palmar erythema, Dupuytren’s contracture) Face Face Eyes (conjunctival pallor, sclera for jaundice, periorbital xanthelasma) Oral exam (ulcers, glossitis/stomatitis) Face - pathology photo_camera Show this photo when the candidate looks at the patient's eyes Identifies icteric sclera/jaundice Face - pathology photo_camera Show this photo when the candidate looks at the patient's mouth Identifies glossitis Torso Torso inspection Spider naevi Gynaecomastia Loss of axillary hair Abdomen inspection Closer inspection Close inspection undertaken Abdomen inspection - pathology photo_camera Show this photo when the candidate looks at the patient's abdomen Identifies abdominal distension Identifies spider naevi Identifies distended abdominal veins Palpation 1 Palpation 1 - general abdomen Light palpation first Deep palpation Palpates all 9 areas Palpation 2 Palpation 2 - liver Invites patient to take breaths in and out Candidate starts palpation in RIF and works up to right costal margin Candidate palpates for liver edge during inspiration Palpation 3 Palpation 3 - spleen Invites patient to take breaths in and out Candidate starts palpation in RIF and works up to left costal margin Candidate palpates for spleen edge during inspiration Palpation 4 Palpation 4 - kidneys Anterior hand firm in the deep palpation position Attempts to ballot the kidney with the other hand in costophrenic angle Manoeuvre repeated for the other kidney Palpation gen Palpation general technique Palpation at eye level initially Watches patients face during palpation Invites patient to make candidate aware if any pain or discomfort Percussion Percussion Percusses upper and lower borders of liver and spleen Shifting dullness or fluid thrill assessed for correctly Percussion - pathology When the candidate percusses the abdomen: tell the percussion note is dull in the flanks; if they examine for shifting dullness correctly, tell them this is present Identifies presence of ascites Auscultation Auscultation Listens to bowel sounds Comments if bowel sounds are: active, sluggish or tinkling Closing Closing examination Thanks patient Invites patient to get re-dressed Washes hands Summary Candidate summary Summarises pertinent findings Coherent summary States would complete examination by examining external hernial orifices, external genitalia, and digital rectal examination Reaches diagnosis Patient Patient score Candidate did not cause any pain to patient Candidate was polite throughout examination Question What is the diagnosis? Chronic liver disease Jaundice and ascites suggest decompensation Question Please list some causes of chronic liver disease Alcohol Autoimmune Non-alcoholic steatohepatitis Chronic viral hepatitis Metabolic (e.g. haemochromatosis) Question What complications can occur secondary to liver cirrhosis? Ascites Hepatocellular carcinoma Encephalopathy Variceal bleeding due to portal hypertension Hepatorenal failure Submit your answers to get your score.