A printer friendly checklist can be found here.

Examination of any system should start with inspection. The patient should be lying comfortably with adequate exposure. The room should be quiet and warm. Stand on the patient’s right hand side and, when palpating, use your right hand.
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1.             INTRODUCTION
A.            Wash hands with alcohol gel or water.
B.            Introduce self and seek permission to examine the abdominal system.
C.            Confirm patient’s name and date of birth.
D.            Ask if patient is currently in any pain or discomfort and ask to point to any area of pain.
E.            Position patient supine with one pillow with chest and abdomen adequately exposed.

2.             GENERAL INSPECTION
A             General (discomfort, distension, colour, muscle wasting, scratch marks, spider naevi)
B.            Inspect hands.
C.            Inspect eyes.
D.            Inspect mouth.
E.            Inspect chest and axillae.
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INSPECTION

A.        Observe patient generally

for evidence of pain or discomfort abdominal distension, pallor, colour (is he yellow? Jaundice.  Does he look anaemic from e.g. bleeding varices/insidious losses/iron malabsorbtion?), muscle wasting, scratch marks, spider naevi and purpura.

Purpura is due to spontaneous bleeding into the skin and there are many causes of purpura. One cause may be chronic liver disease and the associated clotting factor deficiencies. (See note about differentiation with spider naevi below.)

B.        Inspect both hands

and assess for signs of liver disease
Look for example for finger clubbing, leuconychia (white nails), koilonychia (also a sign of anaemia), palmar erythema, Dupuytren’s contracture, spider naevi and purpura.

Abdominal causes of clubbing include cirrhosis, ulcerative colitis, Crohn’s disease and coeliac disease.

Palmar erythema is erythema which spares the centre of the palm. It may be due to increased circulating levels of oestrogens (and therefore found in liver disease, pregnancy and the oestrogen contraceptive pill.)

Dupuytren's contracture is a thickening and subsequent contracture of the palmar aponeurosis. The cause of Dupuytren’s contracture is often not known, although it tends to run in families. In most people no specific cause is found, however it tends to be more common in people with cirrhosis of the liver, diabetes, and alcohol dependence.

If there is any evidence of liver disease then look for a flapping tremor as further evidence of liver failure. (Ask patient to hold hands outstretched with wrists extended back and fingers spread out, and observe for a twitchy coarse irregular flapping tremor.  Be sure not to confuse this with the tremor of Carbon dioxide retention)

C.        Inspect eyes

for xanthelasma (yellowish papules around the eyes indicative of hyperlipidaemia), jaundice, pallor (anaemia)
In the context of the abdominal examination xanthalasma around the eyes might suggest prolonged cholestasis in e.g. primary biliary cirrhosis.
The best place to inspect for jaundice is the sclera of the eyes. Pull down the lower eyelid and look at the sclera which is the tough white sheath that forms the outer-layer of the eyeball. It is normally white, but is yellow in jaundice. 

When you have pulled down the eyelid take the opportunity to also look at margin of the eyelid, the conjunctiva, for the pallor of anaemia. (The conjunctiva is the thin delicate mucous membrane that covers the front of the eyes and also lines the insides of the eyelids – there should be a definite pink line between eyeball and eyelid.) If there is significant bleeding from the gastrointestinal tract or malabsorption of iron, folate or vitamin B12, anaemia may result. Supporting evidence of anaemia (angular stomatitis and atrophic glossitis) may be found when you go on to examine the mouth and also look at the nails (koilonychia).

D.        Inspect mouth

as well as lips, tongue, teeth, gums, breath for pigmentation, telangiectasia, stomatitis and glossitis, ulcers, dentition, gingivitis and odours.

Look at lips for pigmentation (the brown freckly pigmentation of Peutz-Jehger’s Syndrome - very rare) and telangiectasia (Hereditary Haemorrhagic Telangiectasia.)

Telangiectasia are red spots or “blebs”, and are actually tiny malformed blood vessels. They are seen particularly on the lips, buccal mucosa, tongue and fingertips. The important point is they may also occur in the gut, lung and nose and cause severe bleeding.

Look at the open mouth for stomatitis and glossitis as evidence of iron deficiency anaemia.  Angular stomatitis can occur due to candidal infection or chronic anaemia.

Look in the mouth at the buccal mucosa and tongue (including underside of tongue for telangiectasia), for telangiectasia, ulcers, pigmentation and candidiasis (whitish plaques).
Aphthous ulcers are common and painful, herpetic ulcers may occur in crops and a painless non healing ulcer should alert you to squamous cell carcinoma.

Check the state of the gums and teeth.

Check breath for odours (e.g. alcohol, the acetone smell of ketosis or the musty smell of hepatic failure).

Visualise the tonsils if present.

Look for signs on the tongue – wasting due to neurological problems or an enlargement due to hypothyroidism, acromegaly or 1° amyloidosis.

Check for normal swallowing.

E.         Inspect chest and axillae.

Inspect chest for spider naevi, gynaecomastia in men, and axillae for loss of axillary body hair
Gynaecomastia and loss of axillary hair in men: Chronic liver disease may result in feminization of the male due to increased circulating oestrogens and decreased testosterone, although this can also be a side effect of numerous drugs.

Spider naevi are telangiectasia and are most commonly found on the face and the anterior chest wall. They comprise a central arteriole which feeds tiny radiation vessels. (Looks like a spider.) If you press on the centre it will blanch. On removing your finger you will then see the blood refill the “legs of the spider”.  One or two spider naevi may occur in normal people, thyrotoxicosis and pregnancy. If more than 5 are present they are considered significant and likely to be due to chronic liver disease. (By contrast when pressure is applied to purpura the spots do not blanch.)

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3.             INSPECTION OF ABDOMEN
A.             Inspect for movement, distension, scars, herniae, masses, dilated veins and abnormal pulsations.
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Inspection of Abdomen

With imaginary lines, divide the abdomen visually into 9 regions to assist with any description.  You do not need to be exact, but the two vertical lines used are the mid-clavicular lines and the two horizontal lines are a line at a level halfway between xiphisternum and umbilicus and the transtubercular plane.



Right
Hypochondrium


Epigastrium


Left
Hypochondrium


Right
Lumbar


Umbilical


Left
Lumbar


Right Iliac
Fossa


Suprapubic
 or (hypogastric)


Left Iliac
Fossa

 

 

 

 

 

 Abdominal wall contour and movement:-

Look at abdomen to check that it is symmetrical and moves gently out on inspiration. Look for visible peristalsis (an abnormal sign). If the patient has peritonitis and abdominal rigidity there will be no visible movement with respiration.  Crouching down and ‘skylining’ the abdomen is a good idea.

Look for distension. The causes of a swollen abdomen may be conveniently remembered by the “five F’s”:-
                         Fluid, flatus, fat, foetus, and faeces

Look for abdominal herniae - localised bulges which occur in areas of weakness of the abdominal wall. If a hernia is visible ask the patient to cough or sit up and the bulging will increase with the rise in intra-abdominal pressure.
Examples of herniae:

  1. Epigastric – through midline
  2. Umbilical – localized to navel
  3. Paraumbilical – just above/below umbilicus
  4. Direct/indirect inguinal
  5. Femoral

Look for scars of previous surgery e.g. grid-iron scar in right iliac fossa used for access to appendix.

Striae are stretch marks e.g. caused following stretching by pregnancy or obesity. One important medical cause of striae is Cushing's Syndrome – these striae tend to be reddy-purple in colour and more substantial.

Distended veins may be present in portal hypertension in chronic liver disease, and in inferior vena cava obstruction.  ‘Milking’ the vein can show the direction of blood flow.

Pulsations in the abdomen are usually due to the abdominal aorta and are normally seen in thin patients.

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4.             PALPATION OF ABDOMEN FOR ORGANS AND MASSES
A.            Superficial palpation in each of the 9 regions beginning away from any area of pain.
                         (Palpate for rigidity, tenderness, guarding, rebound and masses whilst observing face.)
B.            Deep palpation
                         Repeat sequence with deeper palpation throughout the 9 regions and assess any masses felt
                         Palpate for liver, spleen, ballot for enlargement of kidneys and palpate abdominal aorta.
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Palpation of Abdomen

Position your patient lying flat, with one pillow under head and with adequate exposure of the abdomen. Try to make sure that room is warm and patient is as relaxed as possible with his hands at his side. If necessary ask patient to flex knees to relax abdomen.

Examiners position: crouch or kneel beside the patient. It is important to have warm hands.
Ask patient to point to any areas of tenderness or pain. Start examination away from site of any tenderness or pain. Examine the nine regions systematically (usually clockwise) finishing with umbilical region.

There are 2 types of palpation: - Superficial and Deep Palpation

Superficial Palpation

This is l ight palpation:- using the pulps of your fingers, bending fingers at knuckles (MCP joint). Do not use finger tips. Move (roll) your hand over abdomen keeping contact with the abdomen. Ask patient to tell you if it is tender when you press. Look at the patient’s face while you examine for evidence of tenderness or pain. Assess any tender areas for guarding and rebound tenderness. Guarding is instantaneous contraction of muscle over an inflamed organ or peritoneum. Rebound tenderness is another sign of an inflamed peritoneum. Pain is experienced after quickly lifting your hand off the affected area.

Deep Palpation

Repeat the sequence with deep firmer (or bimanual palpation) in the 9 regions. Assess with deep palpation any abnormal masses found on light palpation.

Palpate for enlarged organs
Then perform deep (respiratory) palpation for liver, spleen and kidneys. (Liver is not normally palpable but may just be palpable in very thin normal subjects. Sometimes the lower pole of the right kidney is just felt in normal subjects.)

Liver
Start examination in right iliac fossa (RIF) and move towards the right costal margin asking patient to take deep breaths in and out. Use tips of 2nd and 3rd right fingers (or radial side of right index finger if you prefer) to feel for the liver edge. Move your hand up with each expiration.
(Note that on inspiration the liver moves down in the abdomen, and this may assist you in feeling the liver edge in an enlarged liver.)

Spleen (stand to examine the spleen)
Perform a similar palpation for an enlarged spleen. Again, start in right iliac fossa (to avoid missing a very large spleen) and perform respiratory palpation moving towards the left costal margin.
Kidneys using a bimanual technique in the flanks ballot for kidneys bilaterally. Finally palpate abdominal aorta.

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5.             PERCUSSION OF ABDOMEN
A.             Percuss for liver.
B.             Percuss for spleen.
C.             Percuss flanks for dullness and demonstrate shifting dullness or fluid thrill (palpation) if appropriate.
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Percussion of Abdomen

The percussing finger is the middle finger of your right hand.  Movement is at the right wrist joint and volume is increased by pushing harder on the abdomen with the percussed middle   finger of your left hand.

 

Percussion note examples

Gas filled structures (bowel)

Resonant

Solid organs

Dull

Distension (flatus)

Tympanic (hyper resonant)

Fluid (ascites)

Dull in flanks and shifts when roll

 

 

Percuss for lower and upper border of liver.
The liver is dull to percussion therefore first percuss below the liver in an area that should be resonant. Percuss upwards until the note becomes dull. Then percuss for the upper margin (which is usually in the 6th intercostal space), beginning just above the right nipple and percuss downwards. The resonant note should become dull in the 6th interspace.

Percuss upwards in the left hypochondrium for the lower border of spleen, beginning in an area where the percussion note should be resonant.

Percuss in flanks. The percussion note should be resonant. If dull it suggests fluid and you would then go on to demonstrate shifting dullness on percussion by asking patient to roll over towards you onto his side. Percuss again in the right flank and the note should now have become resonant as the fluid moves.
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6.             AUSCULTATION
A.            Auscultate for bowel sounds and abdominal aorta bruit.
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Auscultation

Auscultate the abdomen, listening for bowel sounds, which are normally gurgling sounds. If you do not immediately hear bowel sounds you may have to listen for up to one minute. Absent bowel sounds suggest a paralytic ileus or, if the abdomen is rigid, peritonitis.  Tinkling bowel sounds suggest an obstruction.

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7.             SIT PATIENT FORWARD
A.            Inspect back.
B.            Palpate for renal tenderness.
C.            Auscultate for renal bruits.
E.            Palpate neck for cervical lymphadenopathy.
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Inspect back for renal scars.
Palpate for renal tenderness in loins.
Auscultate for renal bruits on either side of midline.
While sitting patient forward, complete the examination by palpating neck for lymphadenopathy.

From behind the patient
Use your index, middle and ring fingers together to gently palpate both supraclavicular fossae. Troisier's sign is the finding of a palpable left supraclavicular lymph node.

Tumours of chest and abdomen usually metastasise to the lower part of the left posterior triangle deeply in the angle between the sternocleidomastoid and clavicle. Lymph drains from the gut to this node. A palpable node (sometimes called Virchow's node) may indicate gastrointestinal malignancy, commonly of the stomach (but remember it could possibly be lung cancer.)

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8.             OTHER AREAS
A.            Inspect and examine groin for hernias and lymphadenopathy.
B.             Examine external genitalia.
C.             Perform digital rectal examination.
D.             If appropriate palpate and percuss for distended bladder.

9.             CONCLUSION
A.            Look at observation charts and test urine with dipstix.
B.            Thank patient and wash hands with alcohol gel or water.
C.            Summarise and present findings in patient’s notes and orally.
 
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