PACES23 Station 1: Mastering Abdominal Examination

The abdominal encounter rewards structure, not speed. In PACES23, it also rewards conversation, judgement and long-term thinking — because all four marking domains are now scored at every station.

Ask any recent candidate and they will tell you the same thing: the abdominal half of Station 1 is the most predictable part of the entire MRCP PACES carousel — and yet every diet, strong candidates fail it by examining beautifully but presenting poorly, or by palpating the abdomen while missing the diagnosis sitting on the patient's lips, wrists and chest wall.

This guide gives you a repeatable routine, the finite list of high-yield presentations, a presentation framework, and a clear map of how the four PACES23 domains are scored during a ten-minute abdominal encounter.

Why This Single Encounter Decides So Much

Under the PACES23 format, your carousel consists of five 20-minute stations, each containing two linked 10-minute encounters. Station 1 classically pairs a respiratory case with an abdominal case, and the abdominal encounter is where preparation converts most reliably into marks:

• The case list is finite. Roughly a dozen presentations account for the overwhelming majority of encounters across diets.

• The signs are visible and repeatable. Spider naevi, transplant scars, arteriovenous fistulae and stomas do not hide.

• Every domain is scored everywhere. Since PACES23, a single examiner per station scores each encounter against Clinical Skills, Managing Patients' Concerns, Clinical Judgement and Managing Long-Term Conditions. A flawless but silent, management-free examination no longer passes on technique alone.

How the Ten Minutes Typically Unfold

You will receive a brief instruction, for example: This 58-year-old man has abdominal distension. Please examine his abdominal system.

• Minutes 0–1: Introduction, consent, hand hygiene, positioning, exposure with dignity, ask about pain.

• Minutes 1–7: Structured examination, periphery to centre, talking to the patient as you go.

• Minutes 7–10: Present your findings, give a differential, outline initial investigations and management, answer focused questions.

Protect the final three minutes. Candidates who examine for nine minutes and present for one routinely fail the judgement and communication domains regardless of how elegant their palpation was.

The Routine: Periphery to Centre

The commonest fatal error is diving straight into the abdomen. In PACES, most abdominal diagnoses announce themselves at the hands, the face or the chest wall before you ever palpate.

Before You Touch the Patient

• Introduce yourself, confirm identity, gain consent.

• Clean your hands with alcohol gel — before and after.

• Position the patient supine with the head on a single pillow and arms at the sides.

• Expose from chest to knees, preserving dignity with a sheet.

1. Hands and Arms

2. Face, Mouth and Neck

• Eyes: jaundice, conjunctival pallor, xanthelasma, corneal arcus.

• Lips and mucosa: pigmented macules (Peutz-Jeghers), mucosal pigmentation (Addison disease), telangiectases (HHT), aphthous ulcers (IBD, coeliac).

• Facies: moon face and plethora (Cushing), parotid enlargement (alcohol), acromegalic features (hepatomegaly), malar flush.

• Neck: raised JVP (congestive hepatomegaly), Virchow node, generalised lymphadenopathy (lymphoma with splenomegaly).

3. Chest

• Spider naevi (significant when multiple), gynaecomastia, loss of body hair, and gynaecomastia-related stigmata of chronic liver disease.

4. Inspection of the Abdomen

Scars tell stories — learn to read them:

Also inspect for:

• Stomas: spouted ileostomy in the right iliac fossa; flush colostomy, commonly left iliac fossa; ileal conduit with urine output.

• Distension: the five Fs — fat, faeces, flatus, fluid, fetus; flank fullness suggests ascites; epigastric prominence with expansile pulsation suggests an aortic aneurysm.

• Veins: caput medusae — periumbilical veins radiating outward suggest portal hypertension; cephalad flow over the flanks suggests IVC obstruction.

• Other: visible peristalsis (obstruction), umbilical and incisional hernias, erythema ab igne, striae, Tenckhoff catheter for peritoneal dialysis.

5. Palpation

• Kneel at the patient's right side; ask about pain and start palpation away from it.

• Light then deep palpation across all nine regions, watching the face.

• Liver: from the right iliac fossa on inspiration; characterise the edge — smooth and tender (hepatitis, congestion), smooth and non-tender (infiltration, congestion), craggy (metastases, HCC). Percuss the span before declaring hepatomegaly — a normal liver span is around 12 cm in the mid-clavicular line, and a Riedel lobe mimics enlargement.

• Spleen: begin in the right iliac fossa, move toward the left hypochondrium, then roll the patient toward you with your left hand supporting the lower ribs posteriorly.

• Kidneys: bimanual ballottement in both loins; bilateral irregular masses suggest polycystic disease.

• Aorta: place a finger either side of the pulsation — an aneurysm is expansile, not simply transmitted.

• Ascites: shifting dullness (roughly a litre or more), fluid thrill in tense ascites.

Spleen or left kidney?

6. Percussion and Auscultation

• Percuss the liver span, Traube space, and for shifting dullness.

• Auscultate bowel sounds (absent in ileus or peritonism; tinkling in obstruction), a succussion splash (gastric outlet obstruction), and bruits (renal artery stenosis, hepatic bruit in HCC).

7. The Closing Statement

To complete my examination, I would examine the hernial orifices and external genitalia, perform a digital rectal examination, dipstick the urine, measure the blood pressure and postural drop, review observations and fluid balance, and assess for peripheral oedema and signs of encephalopathy such as asterixis.

Ten Presentations You Cannot Afford to Miss

1. Chronic liver disease with cirrhosis

Spot it: leuconychia, palmar erythema, Dupuytren, spider naevi, gynaecomastia, loss of body hair, jaundice, bruising, ascites, caput medusae, splenomegaly, asterixis.
Say it: chronic liver disease with portal hypertension, decompensated if ascites, encephalopathy, jaundice or bleeding are present.
Manage it: cause screen — viral serology, autoantibodies and immunoglobulins, ferritin with transferrin saturation, caeruloplasmin if young, alpha-1-antitrypsin, alcohol and metabolic history; ultrasound with elastography; endoscopy for varices.
Long-term domain: variceal prophylaxis with a non-selective beta-blocker such as carvedilol or band ligation; six-monthly ultrasound surveillance for hepatocellular carcinoma per NICE cirrhosis guidance (NG50); alcohol support, nutrition, vaccination, and transplant assessment when indicated.

2. Hepatomegaly — the differential sieve

Structure causes as infective, congestive, infiltrative, malignant, haematological and biliary. Craggy hepatomegaly points to metastases or HCC — remember to seek the primary and check AFP. Smooth tender hepatomegaly suggests hepatitis or congestive cardiac failure, so examine the JVP.

3. Splenomegaly with hepatomegaly

Think portal hypertension, lymphoma, myeloproliferative neoplasm, infection (EBV, malaria) and infiltrative disease. Look for lymphadenopathy and stigmata of chronic liver disease to separate the groups.

4. Massive splenomegaly

The classic quintet: CML, myelofibrosis, malaria, kala-azar and Gaucher disease. Check for anaemia, gout and pruritus of myeloproliferative disease; ask the examiner for a blood film and JAK2 studies.

5. Renal transplant recipient

Spot it: iliac fossa Gibson scar, sometimes a palpable graft, arteriovenous fistula, peritoneal dialysis scars, ciclosporin gum hyperplasia, steroid-related skin changes.
Long-term domain: immunosuppression adherence, infection and skin cancer vigilance, cardiovascular risk reduction, graft function monitoring — a gift of marks for the Managing Long-Term Conditions domain.

6. ESKD and dialysis access

Describe the fistula site and any aneurysmal change or scars of previous access; mention complications — steal syndrome, infection, thrombosis, high-output cardiac failure. A Tenckhoff catheter signals peritoneal dialysis.

7. Autosomal dominant polycystic kidney disease

Spot it: bilateral irregular ballottable flank masses ± hepatomegaly ± hypertension.
Manage it: U&E and eGFR, ultrasound with age-specific cyst criteria, MRI where needed; ACE inhibitor or ARB for blood pressure; tolvaptan for rapidly progressing disease (NICE TA508); pain management.
Long-term domain: family screening and genetics, intracranial aneurysm awareness with family history, transplant planning.

8. Inflammatory bowel disease

Spot it: clubbing, aphthous ulcers, erythema nodosum, pyoderma gangrenosum, right hemicolectomy scar, ileostomy, appendicectomy scar, perianal disease.
Long-term domain: colorectal surveillance, osteoporosis prevention on steroids, vaccination before immunosuppression, VTE risk, and consider PSC if jaundice coexists.

9. The dermatological giveaway cases

• HHT: lip and tongue telangiectases, epistaxis history, iron deficiency.

• Peutz-Jeghers: lip and buccal pigmentation, obstruction scars, GI and pancreatic cancer risk.

• Neurofibromatosis type 1: cafe-au-lait patches and cutaneous neurofibromas with GI involvement.

• Haemochromatosis: bronze pigmentation, hepatomegaly, diabetes, second and third MCP arthropathy.

• Addison disease: pigmentation of skin, palmar creases, scars and buccal mucosa — ask for a postural drop.

• Acanthosis nigricans: insulin resistance, or flag gastric malignancy if new and rapid.

10. Aneurysm and stomas

An expansile pulsatile epigastric mass mandates urgent vascular review and urgent ultrasound — say the word rupture and you demonstrate safe judgement. For stomas, identify the type, comment on health of the mucosa and skin, and mention parastomal hernia, retraction and high-output complications.

The 90-Second Presentation Framework

Present in five moves:

1. Positive findings summarised fluently.

2. Relevant negatives that show you looked deliberately.

3. Lead diagnosis with reasoning, plus two differentials.

4. Initial investigations — bedside, bloods, imaging.

5. Immediate management plus the long-term plan.

This gentleman has leuconychia, palmar erythema, multiple spider naevi and gynaecomastia. He has tense ascites with shifting dullness, caput medusae and a spleen tip palpable, consistent with decompensated chronic liver disease with portal hypertension. I would ask about alcohol and risk factors for viral hepatitis. My initial investigations include full blood count, liver and renal profile with coagulation, ascitic tap for cell count and culture, and an abdominal ultrasound. I would treat his ascites with sodium restriction and diuretics, screen for spontaneous bacterial peritonitis, and arrange endoscopy for varices alongside six-monthly hepatocellular carcinoma surveillance.

That single paragraph touches all four domains — which is exactly why PACES23 rewards this structure.

How Each PACES23 Domain Is Scored Here

Ten Pitfalls That Cost Marks

1. Palpating the abdomen first and missing the peripheral stigmata.

2. Calling hepatomegaly without percussing the liver span.

3. Failing to reposition the patient when hunting the spleen.

4. Missing the obvious — stoma bag, fistula, transplant scar, PD catheter.

5. Examining in silence — no rapport, no explanation.

6. Running out of time before presenting.

7. A differential list without structure or investigation plan.

8. No mention of long-term surveillance or patient explanation.

9. Forgetting completion steps — hernial orifices, PR, urinalysis, blood pressure.

10. Being rough — starting palpation over the site of pain.

A Two-Week Practice Loop

Ward patients are ideal, but not always available at scale — online AI patient simulations and practice partners can supply the repetitions of the routine and, crucially, of the presentation. Record yourself. The voice you hear on the recording is the voice the examiner will hear.

The Final Word

The abdominal encounter in PACES23 Station 1 is not a test of palpation alone — it is a ten-minute demonstration that you can examine systematically, respect the patient, reason safely and plan for the decade after discharge. Master the routine, know your finite case list, and rehearse the presentation until it is automatic. Do that, and the abdominal encounter becomes not the station you fear, but the marks you bank.

Good luck — and start at the hands.