The abdominal examination frequently appears in OSCEs and this guide demonstrates how to perform the examination in a systematic manner, with an included video guide. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Expose patient’s chest and abdomen Position patient – on the bed, sat upright for the first part of the examination Ask if patient currently has any pain before you begin General inspection Look around bedside for treatments or adjuncts – feeding tubes /stoma bags /drains Patient’s appearance – pain / agitation / confusion Body habitus – obese / low BMI / cachectic Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy) Jaundice – cirrhosis / hepatitis Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding Abdominal distention – ascites / bowel distension / large masses Masses – may suggest malignancy / organomegaly Dressings – may be covering wound sites – infection / bleeding Needle track marks – Hepatitis / HIV Excoriations – pruritus – cholestasis Inspection Hands Clubbing – inflammatory bowel disease / cirrhosis / coeliac disease Koilonychia – spooning of the nails – chronic iron deficiency Leukonychia – whitened nail bed – hypoalbuminemia (liver failure / enteropathy) Palmar erythema – reddening of palms – liver disease / pregnancy Dupuytren’s contracture: Thickening of the palmar fascia Associated with alcohol excess / family history Hepatic flap: Ask patient to stretch out arms, with hands dorsiflexed and fingers outstretched Ask them to hold their hands in that position for 15 seconds The hands will flap (flex/extend at the wrist) in an irregular fashion if positive Causes include – hepatic encephalopathy / uraemia / CO2 retention Arms Bruising – may suggest abnormal coagulation – e.g. secondary to liver failure Petechiae – low platelets – e.g. splenomegaly Excoriations – cholestasis Track marks – intravenous drug use – Hepatitis / HIV Axillae Lymphadenopathy – malignancy / infection Hair loss – malnourishment / iron deficiency anaemia Acanthosis nigricans (hyperpigmentation) – GI adenocarcinomas / obesity Eyes Xanthelasma – raised yellow deposits surrounding eyes – hyperlipidaemia Ask patient to lower one of their eyelids with their finger. Inspect for the signs below. Conjunctival pallor – suggests significant anaemia Jaundice – noted in the sclera – haemolysis / hepatitis / cirrhosis / biliary obstruction Mouth Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12 deficiency Oral candidiasis – white slough on oral mucous membranes – iron deficiency / immunodeficiency Mouth ulcers – Crohn’s disease / coeliac disease Tongue (glossitis) – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency Neck Cervical lymph nodes – lymphadenopathy may indicate infection / metastatic malignancy Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy Chest Spider naevi – central red spot with reddish extensions (>5 significant) – chronic liver disease Gynaecomastia – overdevelopment of male mammary glands (pseudofeminisation) – liver cirrhosis / digoxin/ spironolactone Hair loss – pseudofeminisation/ malnourishment / iron deficiency anaemia Detailed abdominal inspection Position the patient supine, with their arms by their side and legs uncrossed Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy) Masses – assess (size/position/consistency/mobility) – organomegaly / malignancy Pulsation – a central pulsatile and expansile mass may indicate an abdominal aortic aneurysm (AAA) Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed (pancreatitis/ruptured AAA) Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed (pancreatitis/ruptured AAA) Abdominal distension – fluid (ascites) / fat (obesity) / faeces (constipation) / flatus / fetus (pregnancy) Striae – reddish/pink (new) or white/silverish (chronic) – abdominal distension Caput medusae – engorged paraumbilical veins – portal hypertension Stomas – colostomy (LIF) / ileostomy (RIF) / urostomy (RIF and contains urine) Palpation Ask about any areas of pain and examine these last. Kneel so that you are level with the patient. Observe the patient’s face throughout for signs of discomfort. Light palpation Palpate each of the 9 abdominal regions, assessing for any of the below. Tenderness – note the areas involved and the severity of the pain Rebound tenderness – pain is worsened on releasing the pressure – peritonitis Guarding – involuntary tension in the abdominal muscles – localised or generalised? Masses – large/superficial masses may be noted on light palpation Deep palpation Assess each of the 9 regions again, but with greater pressure applied during palpation. If any masses are identified then assess: Location – which region? Size Shape Consistency – smooth / soft / hard / irregular Mobility – is it attached to superficial/underlying tissues? Pulsatility – a pulsatile mass suggests vascular aetiology Liver 1. Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger) 2. Press your hand into the abdomen as you ask the patient to take a deep breath 3. Feel for a step, as the liver edge passes below your hand 4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher If you feel the liver edge, note the following: Degree of extension below the costal margin Consistency of the liver edge (smooth/irregular) Tenderness – suggestive of hepatitis Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation Gallbladder The gallbladder is not usually palpable. An enlarged gallbladder suggests obstruction to biliary flow/infection (cholecystitis). Perform palpation at the right costal margin, mid-clavicular line (9th rib tip). If enlarged, a rounded mass moving with respiration may be palpated (note any tenderness). Murphy’s sign: Place your hand in the area noted above (right costal margin, mid-clavicular line) Ask the patient to take a deep breath As the gallbladder is pushed down into your hand the patient may suddenly develop pain and stop inspiring. If this occurs and there is no discomfort in the same location on the left side of the abdomen then this is known as a positive Murphy’s sign, which is suggestive of cholecystitis Spleen The spleen only becomes palpable when it’s at least three times its normal size! 1. Start in right iliac fossa – massive splenomegaly can extend this far! 2. Align your fingers in the same direction as the left costal margin 3. Press your right hand into the abdomen as you ask the patient to take a deep breath 4. Feel for a step, as the splenic edge passes under your hand (a notch may be noted) 5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the left hypochondrium Kidneys 1. Place your left hand behind the patient’s back, at the right flank 2. Place your right hand just below the right costal margin in the right flank 3. Press your right hand’s fingers deep into the abdomen 4. At the same time press upwards with your left hand 5. Ask the patient to take a deep breath 6. You may feel the lower pole of the kidney moving inferiorly during inspiration 7. Repeat this process on the opposite side to assess the left kidney Aorta 1. Palpate using fingers from both hands 2. Palpate just above the umbilicus at the border of the aortic pulsation 3. Note the movement of your fingers: Upward movement = pulsatile Outward movement = expansile (suggestive of AAA) Bladder An empty bladder will not be palpable (pelvic). However, an enlarged full bladder can be felt arising from behind the pubic symphysis. This may suggest a diagnosis of urinary retention. Percussion Abdominal organs Liver – percuss up from RIF then down from right side of chest to determine the size of the liver Spleen – percuss up from RIF moving towards the left hypochondrium to assess for splenomegaly Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder (dull) / bowel (resonant)) Shifting dullness 1. Percuss from the centre of the abdomen to the flank until dullness is noted 2. Keep your finger on the spot at which the percussion note became dull 3. Ask patient to roll onto the opposite side to which you have detected the dullness 4. Keep the patient on their side for 30 seconds 5. Repeat your percussion in the same spot 6. If fluid was present (ascites) then the area that was previously dull should now be resonant 7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull (i.e. the dullness has shifted) Auscultation Bowel sounds Normal – gurgling Abnormal – e.g. “tinkling” (bowel obstruction) Absent – ileus / peritonitis Bruits Aortic bruits – auscultate just above the umbilicus – AAA Renal bruits – auscultate just above the umbilicus, slightly lateral to the midline To complete the examination Thank patient Wash hands Summarise findings Suggest further assessments and investigations Check hernial orifices – e.g. if there’s signs of obstruction – Perform a digital rectal examination (PR) – e.g. if there’s a suggestion of an upper GI bleed Perform an examination of the external genitalia – if appropriate “I would examine the hernial orifices, perform a PR and examine the external genitalia if appropriate” Source
