Introduction

Wash hands
Introduce yourself
Confirm patient details name / DOB
Explain the examination
Gain consent
Expose patients chest & abdomen
Position patient on the bed, sat upright for the first part of the
examination
Ask if patient has any pain

General inspection

Look around bedside for treatments or adjuncts feeding tubes /stoma

bags /drains
Patients appearance in pain? / agitated? / confused?
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
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General inspection
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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
Dupuytrens contracture:

Thickening of palmar fascia

Associated with alcohol excess / family history

Hepatic flap:

Ask patient to stretch out arms, with hands dorsiflexed &

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

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Inspect hands

Inspect hands

Inspect for nail clubbing

Assess for hepatic flap

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Arms

Bruising may suggest abnormal coagulation (PT) due to liver failure

Petechiae low platelets
Excoriations cholestasis

Track marks intravenous drug use Hepatitis / HIV

Axillae
Lymphadenopathy malignancy / infection
Hair loss malnourishment / iron deficiency anaemia
Acanthosis nigricans (darkened pigmentation) GI adenocarcinomas /
obesity

Eyes

Ask patient to lower one of their eyelids with their finger. Inspect for the
signs below.
Jaundice noted in the sclera haemolysis / hepatitis / cirrhosis, biliary
obstruction
Conjunctival pallor suggests significant anaemia
Xanthelasma raised yellow deposits surrounding eyes
PBC/ hyperlipidaemia

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 Crohns 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
Virchows 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
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Inspect axilla

Inspect sclera

Inspect conjunctiva

Inspect mouth & tongue

Palpate lymph nodes

Palpate Virchow's node

Closely inspect the chest

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Detailed abdominal inspection

Position the patient supine, with their arms by their side & legs
uncrossed.
Scars midline scars (laparotomy) / RIF (appendectomy) / right subcostal
(cholecystectomy)
Masses assess (size, position, consistency, mobility)
organomegaly / malignancy
Pulsation a central pulsatile & expansile mass may indicate an
abdominal aortic aneurysm (AAA)

Cullens sign bruising surrounding umbilicus retroperitoneal bleed

(pancreatitis/ruptured AAA)
Grey-Turners 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 &
contains urine)
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Inspect the abdomen

Inspect for distension / masses

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Palpation

Ask about any areas of pain & examine these last.

Kneel so that you are level with the patient.
Observe the patients 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

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Light palpation

Deep palpation

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Liver

1. Start palpation in the right iliac fossa

2. Press your right hand into the abdomen as you ask the patient to
take a deep breath
3. Feel for a step, as the liver edge passess below your hand
4. If you dont 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

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Liver palpation
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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 round mass moving with respiration may be palpated
note any tenderness
Murphys sign:

Place your hand in the area noted above

Ask the patient to take a deep breath
As the gallbladder is pushed down into your hand the patient may suddenly
develop pain & stop inspiring
This is a positive Murphys sign, which is suggestive of cholecystitis

Spleen
The spleen only becomes palpable when its at least 3x 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 passess under your hand (a
notch may be noted)
5. If you dont feel anything, repeat process with your hand 1-2 cm
closer to the left hypochondrium
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Palpate the spleen

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Kidneys

1. Place your left hand behind the patients back, at the right flank
2. Place your right hand just below the right costal margin in the right
flank
3. Press your right hands 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
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Ballot the kidneys

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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)

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Palpate aorta
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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))
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Percuss out liver borders

Percuss spleen

Percuss bladder

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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)
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Percuss from the midline outwards until dull

Repeat percussion

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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
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Auscultate for bowel sounds

Auscultate for aortic bruits

Auscultate for renal bruits

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To complete the examination

Thank patient
Wash hands
Summarise findings

Suggest further assessments & investigations

Check hernial orifices e.g. if theres signs of obstruction
Perform a digital rectal examination (PR) e.g. if theres 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