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Abdominal examination – chronic liver disease


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):

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  • When the candidate looks in your mouth: show the candidate the following photo (click image):

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  • When the candidate looks at your abdomen: show the candidate the following photo photo (click image):

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  • 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.

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