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.
Confirm patient details – name / DOB
Explain the examination
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
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
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
- Thickening of the palmar fascia
- Associated with alcohol excess / family history
- 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
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
Lymphadenopathy – malignancy / infection
Hair loss – malnourishment / iron deficiency anaemia
Acanthosis nigricans (hyperpigmentation) – GI adenocarcinomas / obesity
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
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
Cervical lymph nodes – lymphadenopathy may indicate infection / metastatic malignancy
Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy
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)
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.
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
Assess each of the 9 regions again, but with greater pressure applied during palpation.
If any masses are identified then assess:
- Location – which region?
- Consistency – smooth / soft / hard / irregular
- Mobility – is it attached to superficial/underlying tissues?
- Pulsatility – a pulsatile mass suggests vascular aetiology
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
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).
- 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
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
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
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)
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.
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))
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)
Normal – gurgling
Abnormal – e.g. “tinkling” (bowel obstruction)
Absent – ileus / peritonitis
Aortic bruits – auscultate just above the umbilicus – AAA
Renal bruits – auscultate just above the umbilicus, slightly lateral to the midline
To complete the examination
Suggest further assessments and investigations
- Check hernial orifices – e.g. if there’s signs of obstruction – see our hernia examination guide here
- 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”
Dr Ally Speight
Consultant in Gastroenterology