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?