Hello Dr. Pelleather. My name is Dr. Punecker. I'm the Sistation III of the MRCGP. This exam will be a abdominal examination. This is Luke at 21-year-old University student who has been referred by his GP to the gastrointrology clinic with abdominal pain and being unwell. Would you like to examine his abdominal system please? Yes, please. Hello, is it Luke? Yes. Nice to meet you. I'm Dr. Pelleather. Is it okay if I examine your abdomen and a few other parts in your body? Yes, that's right. Right, okay. Can I ask you to just take your gown down if that's all right for me? Thank you. So, just having a good nice look at you now, okay? Right, okay. Just going to have a look if you've got any scars or anything anywhere, okay? Right, can I have a look at your hands if that's all right? That's great. You've got any pain anywhere? I know a bit, I think. Okay, thank you for that. Okay, that's great. So, looking for any evidence of the throbbing, I think? No luconica, no other significant nail changes. There's no wasting of the muscles. Okay, can I just ask you to? So, there's no parmateraid theme, no dupetrins contracture. Okay, just stretch your hands, and I'll crop up your wrists like that for me. That's it, brilliant. So, no evidence of any hepatic flap. That's brilliant. Thank you. Thank you very much. So, ideally, I'd like to check his pulse for 30 seconds. All right, can I start with your neck, feeling for any lymph nodes? So, I'll try to be gentle. So, no evidence of any cervical lymphednautathy. I'd like to also check his axillary and anguinal lymph nodes. Okay, we can do that later. Okay, can I, I'm going to pull that on your eyelids. Okay, just looking for any evidence of anemia. Looking up, look down for me. There's a fake tint of yellow pigment in this clearer. Right, okay. Okay, I'm going to pull that on your eyelids. Okay, just looking for any evidence of anemia. Right, okay. Would you like to just lie down flat for me? Please. That's very good, okay. Again, having a good look for any scars, sinuses, any evidence of chronic liver disease, any pitechia, bruising, scratch marks, iodine, ebi, any evidence of any ailevechistulas, is that thing? Okay, I'm just going to gently feel on you tummy now, okay. So, I'll try to get down to the level of the patient. So, I'm just going to gently feel, sorry about that. Okay, I'm going a bit deeper now. A little bit painful. A bit painful there, okay. Okay, I'm just going to feel if I live enough. So, would you be able to just take some nice deep breaths in an outlook for me please? Really then? Sorry about that, sorry. Okay, I'm just going to tap on your tummy now. Okay. Okay. Okay. Just going to feel if you're kidney's now. Lift your back up a bit. That's it, that's it. That's great. Okay. Just going to have a listen. One minute remaining. One minute more. So, now a bit of any hums or brui. Just going to press on your ankles, okay. Looking for any pede la dima. Now, a bit of any pede la dima. Alright, okay. That's great. Thank you very much. You can now address that. Okay, have you finished? So, to complete my examination, I'd like to perform a shifting dullness test. Check his urine dip. And also, I'd like to examine for a full lymphrodenopathy screen, including the axillary and inguinal lymph nodes. And I'd also like to check his observations. Okay. Would you like to present your case now, please? So, I'd examine the 21-year-old university student who's coming with abdominal pain. The only positive findings on my examination were jaundice and a two-finger breath habit of megalia. There was no obvious organometalline or a norther signs of chronic liver disease. There was no other scars or sinuses. Okay. So, tell me, you mentioned about jaundice. Are you sure the patient was jaundiced? So, he had a very faint hint of jaundice. He wasn't overtly jaundiced. Okay. And you mentioned about a two-finger breath habit of megalia. Was the patient tender in his abdomen? Yes. So, he had tender habit of megalia on palpation. Okay. Would you like to think of a few causes of a tender habit of megalia in a young patient, like Luke? Okay. So, top of my differentials would be hepatitis, which could be infective or alcoholic hepatitis. Okay. The other things I would like to rule out would be any kind of malignancies and any infiltrated disorders, but he always syndrome, congestive cardiac failure, all done lightly in his case per his age. And I'd like to do some blood tests and further investigations to look further into the problem. Okay. Well, let's just look at this particular case. What do you think would be the top of your list as a cause of the tender habit of megalia in this 21-year-old student? So, I would be considering hepatitis as a top differential probably vital hepatitis or... Or alcoholic hepatitis. Okay. What if I add in a little piece of history about Luke? He has returned two weeks ago after a holiday to the Central African Republic. What would he like to think about? So, I'd like to start thinking about hepatitis A, hepatitis B, hepatitis C, and hepatitis E. Although hepatitis B would be a bit unlikely taking into history his two weeks history of return. Okay. Okay. Well, let's... Have you come across any blood tests that would either confirm or rule out viral hepatitis? So, for... We'd like to do some theological tests for hepatitis. Okay. For hepatitis A, I'd like to check his... And the hepatitis A antibodies, IgM antibodies, for hepatitis B, I'd like to check his hepatitis B surface antigen. Okay. Hepatitis B core antigordy. Okay. And hepatitis B, E antigen. Right. Which is the antigen that goes up first in hepatitis B. So, that would be hepatitis B surface antigen and hepatitis B core antigordy. Okay. Okay. Let's just come to hepatitis A. What type of antibody is are you expecting to rise initially? So, within the first four weeks period I'd expect to rise in the IgM variety of hepatitis A antibody after birth. Okay. Afterwards, I'd expect that IgG rise. Okay. That's good. Okay. Thank you.