Abdominal examination – OSCE Guide

geekymedics.com/abdominal-examination

October 1, 2010

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.

Inspection
Palpation
Percussion
Auscultation
Completing the examination
Interactive mark scheme
Mark Scheme (PDF)

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

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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

General inspection

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

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 Inspect hands

Inspect hands

Inspect for nail clubbing

Assess for hepatic flap

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

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Eyes
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

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

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 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 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

Inspect for distension / masses

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 Abdominal surgical incision sites

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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?

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

Light palpation

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 Deep palpation

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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

Liver palpation

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)
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 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

Palpate the spleen

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

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 Ballot the kidneys

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)

Palpate aorta

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

Auscultate for bowel sounds

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 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 and investigations

Check hernial orifices – e.g. if there’s signs of obstruction
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”

REVIEWED BY

Dr Ally Speight

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