Abdominal Examination Routine — Viva Defence

Viva — The Abdominal Examination Short-Case Defence

The routine (examiner: "Examine this patient's abdomen")

I would introduce myself, confirm the patient's identity, explain what I am going to do, request permission, position the patient supine with one pillow and the arms at the sides, and expose the abdomen from xiphisternum to symphysis pubis. I would ensure good lighting and a chaperone if appropriate. ^[1]

I perform the twelve-step head-to-toe routine: ^[1]

End of bed. I observe the patient's general appearance — cachectic, with obvious scleral icterus. I note the body habitus, the skin colour (jaundice), the breathing pattern, and the bedside clues. ^[1]

Hands. I examine for clubbing (present — primary biliary cholangitis is a GI cause of clubbing), palmar erythema (present — liver palms), Dupuytren contracture (absent), nail signs (leuconychia from hypoalbuminaemia), and a liver flap (asterixis — I ask the patient to hold their hands out with wrists dorsiflexed for 30 seconds). ^[1]

Arms. I look for bruising (coagulopathy), needle marks, AV fistula, excoriations (pruritus from cholestasis — a hallmark of PBC, often preceding jaundice). ^[1]

Face. I examine the eyes (scleral icterus present, xanthelasma present — PBC causes disordered lipid metabolism, and the patient has periorbital xanthomata), the mouth (angular cheilitis from cholestasis-related fat-soluble vitamin malabsorption), and the lips. ^[1]

Neck. I palpate for a Virchow node (absent — no sentinel sign of malignancy) and the cervical chain. ^[1]

Chest. I examine for spider naevi (more than ten, in the SVC distribution above the nipple line — I confirm by blanching with a glass slide), gynaecomastia, and loss of axillary hair. I note that spider naevi are significant when above five and in the SVC territory. ^[1]