Abdominal Examination Routine — Short Answer Question

SAQ 1 — The Systematic Abdominal Examination Short Case (20 marks, 30 minutes)

Model Answer

(a) The twelve-step sequence and the rationale for auscultating before palpation (4 marks): ^[1]

The abdominal examination is a reproducible head-to-toe twelve-step routine: end of bed, hands, arms, face, neck, chest, inspection, auscultation (before palpation), palpation (light then deep, starting away from pain), percussion, additional examination (hernial orifices, PR, genitalia, stoma), and legs. ^[1]

The unique feature of the abdominal examination — in contrast to the cardiovascular and respiratory examinations — is that auscultation precedes palpation. The rationale is physiological: palpation and percussion physically disturb the bowel, potentially stimulating peristalsis and creating artefactual hyperactive sounds, or suppressing peristalsis and creating artefactual silence. Heart murmurs and breath sounds are generated by organs not mechanically altered by the examiner's hands, so the inspect-palpate-percuss-auscultate sequence is appropriate for those systems. Every examiner watches for this: the candidate who palpates before auscultating has demonstrated they do not understand the basis for the sequence change. ^[1]

(b) Interpretation of palmar erythema, spider naevi, and Dupuytren contracture (4 marks): ^[1]

Palmar erythema is a diffuse, blanchable erythema of the thenar and hypothenar eminences sparing the centre of the palm. It results from oestrogen excess due to impaired hepatic metabolism, causing peripheral vasodilation. It is non-specific (also seen in pregnancy, rheumatoid arthritis, hyperthyroidism) but supports chronic liver disease in context. ^[1]

Spider naevi are bright red, radiating vascular lesions with a central arteriole and capillary branches. The diagnostic test is blanching: press the centre with a glass slide and the entire lesion blanches, then refills from the centre outward. The distribution rule is critical: they appear only in the territory of the superior vena cava — face, neck, upper chest, shoulders, arms. More than five in the SVC distribution is significant. The Udell systematic review found spider naevi have a specificity of approximately 95 per cent for cirrhosis in the appropriate clinical context ^[5]. They also occur in pregnancy and with oral contraceptive use (both oestrogen-excess states).