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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. Check out the abdominal examination OSCE mark scheme here.



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 eyeshyperlipidaemia 

 

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

  • Inspect axilla

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)

  • Inspect the abdomen

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? 

Masseslarge/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 
  • Light palpation

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))

  • Percuss out liver borders

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)

  • Percuss from the midline outwards until dull

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

  • Auscultate for bowel sounds

To complete the examination

Thank patient

Wash hands

Summarise findings

 

Suggest further assessments and investigations

I would examine the hernial orifices, perform a PR and examine the external genitalia if appropriate”


REVIEWED BY

Dr Ally Speight

Consultant in Gastroenterology


 

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