Abdominal Examination

The routine

• Say "may I examine your abdomen"
• Inspect at end of bed for pallor, jaundice, spider naevi.
• Say "Could you hold out your hands straight out please, and cock up your wrists," and inspect for a flapping tremor of ammonia retention for 5-10s.
• Inspect nails for clubbing, leuconychia (low albumin), koilonychia (anaemia), palmer erythema (liver disease). Say, "could you turn your hands over" and feel for dupuytrens contracture (below the little finger).

Face and neck

• Look at eyes for anaemia, icterus, and xanthelasma.
• Look in mouth for cyanosis, ulcers
• Feel lymph nodes, especially left supraclavicular (Virchov's node, classically gastric cancer).

Chest

• Inspect for spider naevi (if present press on them - they are blanching)
• Gynaecomastia, paucity of body hair

Abdomen

• Expose: ideally from nipple to knee, whilst covering genitals
• Inspect for scars, distension, pulsation, caput medusa (veins originating from umbilicus)
• Get patient to take head off bed (hernias on abdomen become prominent), and take a deep breath in and out.
• Say "do you have any pain," and if so get them to point to it. Say "I'm going to touch your tummy, tell me if it is tender at any point."
• Light palpatation , essentially for tenderness. Keep eyes on the patients face (this is not embarrassing although it may feel so initially, as they soon turn their eyes away). Do this sequentially in all areas.
• Deep palpatation , essentially for masses.
• Liver palpatation . Start in right iliac fossa and travel towards right lower rib. Use border of first finger. Push up slightly as you ask them to breath in. Remember to keep looking at their face (for Murphy's sign). Percuss from below and above liver to confirm size.
• Spleen palpatation . Start in right iliac fossa and travel towards left lower rib. Percuss spleen.
• Ballot kidneys: hands on flank, with one hand on top, one hand directly below the body. Press in with the lower hand and feel with the upper. Repeat on other flank.
• Palpate for an aortic aneurysm. Use 2 hands either side of midline. Aneurysms are expansile and pulsatile.
• Shifting dullness (if the abdomen is distended, useless otherwise). Percuss from midline to left flank. If dullness in flank then leave finger over dull area and ask patient to roll towards you then percuss again at this spot, which should now be resonant for a positive test.
• Auscultate for renal artery bruits, and bowel sounds

Other

• Palpate the ankles for oedema

"I would like to"

• Urine dipstick
• Examine the external genitalia
• Perform a PR examination

Common OSCE stations

1. Polycystic kidney disease
2. Hepatomegaly
3. Splenomegaly
4. Hepatosplenomegaly
5. Ascites
6. Chronic liver disease

Presenting

For example:

• This man is jaundiced. He has clubbing and palmer erythema. There is gynaecomastia and spider naevi. There is no lymphadenopathy.
• On examination of his abdomen there is caput medusa. There is tense swelling and the umbilicus is everted. There is shifting dullness, suggesting ascites. The liver is palpable at 3cm below the right costal margin, there is no other organomegaly.
• My diagnosis would be chronic liver disease.

Anatomy