Table of Contents
- Wash hands
- Introduce self
- Ask Patient’s name, DOB and what they like to be called
- Explain examination and obtain consent
- Expose and lie patient flat
- Stand at the foot of the patient’s bed and look at the patient, and then around the bed
- Does the patient look well/unwell? Are they in any pain/discomfort?
- Look for jaundice, pallor, muscle wasting and cachexia
- Look around the bed for paraphernalia, e.g. vomit bowls, intravenous infusions, nutrition, catheter etc.
- Examine for asterixis (flapping tremor) by asking the patient to hold their arms out straight, with their wrists ‘cocked back’ and observe for a flap (flap = hepatic encephalopathy)
- Look for clubbing by asking the patient to place their two index finger nails together – Schamroth window test (cirrhosis, IBD, coeliac disease)
- Leukonychia – pale/white nails (hypoalbuminaemia in liver cirrhosis/enteropathy)
- Koilonychia – spoon shaped/flattened nails (iron deficiency)
- Look for palmar erythema (hyperdynamic circulation due to ↑oestrogen levels in liver disease/pregnancy)
- Look and feel for Dupuytren’s contracture – thickened palmar fascia (can be related to alcoholism/liver disease)
- You may also see fingertip capillary glucose monitoring marks (in diabetes)
- Look at the sclera for jaundice (liver disease)
- Ask permission from the patient then pull down the lower eyelid to look for conjunctival pallor (anaemia, e.g. due to GI bleeding, malabsorption)
- And lastly periorbital xanthelasma – yellowish deposit of cholesterol around the eyes (hyperlipidaemia in cholestasis)
- Mouth: ask the patient to open their mouth, look for:
- Glossitis – inflammation and depapillation of the dorsal surface of the tongue (iron/B12 deficiency)
- Stomatitis – mucosal inflammation, including ‘angular stomatitis/chelitis’ at the corners of the mouth (iron/B12 deficiency)
- Aphthous ulcers (IBD)
Neck and torso
Ask patient to sit forwards:
- Neck: briefly examine for cervical lymphadenopathy from posteriorly – especially Virchow’s node in left supraclavicular fossa (classically gastric malignancy)
- Back inspection: look at the back for spider naevi (significant if >5) and any skin lesions (immunosuppression)
Ask patient to sit back:
- Chest inspection, look for:
- Spider naevi – central red capillary spot with deep red extensions that, when pressure is applied, refill from the centre (significant if >5)
- Gynaecomastia – male breast swelling
- Loss of axillary hair (all due to ↑oestrogen levels in liver disease/pregnancy)
Closely look at the patient’s abdomen for:
- Distension (5Fs: Fluid, Flatus, Fat, Fetus, Faeces)
- Striae (pregnancy, Cushing’s syndrome)
- Spider naevi
- Hernias (ask patient to cough)
- Movement with respiration (absent in peritonitis)
- Obvious pulsations, and distended abdominal wall veins/‘caput medusae’ (portal hypertension)
Crouch to patient’s level and gently roll fingers of your right hand over each of the nine regions while watching the patient’s face
Check for: tenderness, guarding (peritonitis), rebound tenderness (peritonitis)
Palpate again but deeply using both hands – the upper hand to exert pressure, the lower hand to feel. (You can be standing for this.)
Check for: masses, deep tenderness and, if relevant, Rovsing’s sign (appendicitis) and Murphy’s sign (cholecystitis).
Ask the patient to breathe in and out deeply.
Using the radial border of the right hand, palpate in increments from the RIF to the right costal margin – push in on each inspiration.
Hepatomegaly may be caused by: metastasis/hepatocellular carcinoma, hepatitis, RVF, leukaemia/lymphoma, fatty liver, alcoholic liver disease.
Palpate the spleen in the same way as the liver, but diagonally from the RIF to the left costal margin. The spleen can be felt better if patient rolls onto their right side with tucked legs.
Splenomegaly may be caused by: lymphoma/leukaemia, myelofibrosis, myeloproliferative disorders, portal hypertension, extravascular haemolysis, malaria/EBV.
Place one hand anteriorly and one posteriorly in the patient’s loin.
Ask patient to expire as you press up into renal angle with your posterior hand and press down with your anterior hand.
As patient breathes in, you may feel the kidney between your hands.
Ballot the kidney by flexing the MCP joints of your posterior hand. Do flick, flick, stop and then repeat as necessary.
Press down with finger tips (one hand each side) in the horizontal plane midway between the umbilicus and xiphoid process, starting laterally and moving medially.
The ulnar borders of your hands should be parallel with the costal margins.
Pulsatile mass, i.e. upward movement, can be normal; expansile mass, i.e. outward movement, suggests AAA.
How to… Differentiate between the spleen and left kidney
- Cannot get above spleen
- Spleen notched
- Spleen not ballotable
- Spleen moves down on inspiration
- Note general percussion quality (tympanic = flatus; percussion tenderness = peritoneal irritation)
- Liver: percuss upwards from the RIF to find the lower border of the liver (normally beneath right costal margin). The percussion note should become dull over the liver. Next, percuss the chest downwards in the right mid-clavicular line to find the upper border of the liver (normally beneath 5th costal cartilage). Ideally, percuss with the patient in expiration.
- Spleen: percuss diagonally from the RIF towards the spleen. The dull percussion note of the spleen is only heard when it is enlarged. Also percuss in Traube’s space, which is just above the left costal margin in the mid-clavicular line (if resonant, there is no splenomegaly).
- Flank: percuss all the way across abdomen in each direction laterally from the midline. The flank should be resonant. If a dull percussion note is heard, go on to demonstrate shifting dullness (have patient roll to other side and percuss again – it should become resonant if the cause is ascites). You could also demonstrate fluid thrill (have patient press hand firmly on abdominal midline while you tap one side and feel the other; fluid wave = ascites).
- Use diaphragm to listen for bowel sounds at ileocaecal valve in RLQ until heard, up to 1 minute (tinkling = obstruction; absent = paralytic ileus/peritonitis)
- Use bell to listen for aortic bruit (midline between xiphisternum and umbilicus; may indicate AAA); and renal bruits (5cm superior and lateral to umbilicus bilaterally; renal artery stenosis)
- Check for pitting oedema by pushing over the tibia for 10 seconds, then run finger over feeling for indent (hypoalbuminaemia)
- Thank patient and restore clothing
- ‘To complete my examination, I would examine the external hernial orifices, the external genitalia, and perform a digital rectal examination.’
- Summarise and suggest further investigations you would consider after a full history
Why don’t you test your knowledge on some examination findings?
Name five causes of abdominal distension
What clinical examination features would suggest decompensation of chronic liver disease?
In what circumstances might you be able to palpate a kidney?
How about some questions around some of the conditions you may see?
What are the causes of hepatosplenomegaly?
What are the complications of stoma formation?
What are the most common pathologies requiring a renal transplant?
Name, describe and list the indications for each of the the three types of colostomy?
How is chronic liver disease managed?
Now try some OSCE stations!
- Normal abdominal exam
- Chronic liver disease
- Renal transplant
- And there’s even more!
Clubbing: 2009 Desherinka, licensed under the Creative Commons Attribution-Share Alike 4.0 International, 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic license and GNU Free Documentation licence 1.2
Dupuytren’s contracture: 2010 James Heilman, MD, Creative Commons Attribution-Share Alike 3.0 Unported license
Xanthelasma: 2005 Klaus D. Peter; licensed under the Creative Commons 3.0 Germany licence
Glossitis: 2011. Grook Da Oger. Licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license
Spider naevi: 2018. James Heilman, MD. Licensed under the Creative Commons Attribution-Share Alike 4.0 International license
Gynaecomastia: 2021. ProloSozz. Licensed under the Creative Commons Attribution-Share Alike 4.0 International license
Ascites (second photo): 2011. James Heilman, MD. Licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license
Peripheral oedema: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license