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James Wight

Examination of the Abdomen

• Wash your hands.

• Introduce yourself to the patient, and ask permission to examine them.
• Expose the patient, and lie them flat.

Look around the bed Oxygen mask/nasal prongs, drips, cigarettes,
special foods, diabetic diet
Look at the patient Comfortable at rest, wound drain, catheter, NG
tube, jaundice, scratch marks, spider naevi,
gynaecomastia, striae, bruising, anaemia,
pigmentation, cachexia, dehydration, abdominal
distension, abdominal masses, scars (rooftop, L-
shape, Mercedes-Benz, subcostal, midline, Lanz,
Hockeystick, inguinal), Sister Mary Joseph
Nodule, Grey-Turner’s/Cullen’s sign, stomas,
acanthosis nigricans, tattoos
Look at the hands Clubbing (cirrhosis, lymphoma, IBD, Coeliac
disease), leukonychia (hypoalbuminaemia),
koilonychias (iron deficiency), palmar erythema,
Dupuytren’s contracture, anaemia, tendon
xanthomata, liver flap
Look at the eyes Jaundice, anaemia, Kayser-Fleischer rings,
Look in the mouth Ulcers, pigmentation, telangiectasia, fetor
hepaticus, Candida, angular stomatitis, gums,
smooth tongue, leukoplakia, atrophic glossitis,


Feel the neck Supraclavicular lymph nodes, particularly

Virchow’s node

→ Inspect the abdomen again, including asking the patient to raise their head or legs

Light palpation In all 9 segments of the abdomen (ask if there’s

any pain first, and watch the patient’s face)
Deep palpation In all 9 segments of the abdomen, watching the
Feel for the liver Starting in the right iliac fossa, asking the patient
to breathe in each time you palpate
Feel for the spleen Starting in the right iliac fossa, asking the patient
to breathe in each time you palpate
Ballot the kidneys Put one hand posteriorly in the flank, and flick the
kidney onto a hand positioned anteriorly
Feel for a AAA Above the umbilicus (the aorta divides below this

Percuss the liver Starting in the right iliac fossa until dull, then
percuss out the upper border
Percuss the spleen Starting in the right iliac fossa
Check for shifting dullness With finger in the midline, move down the
flank until percussion note becomes dull. Ask
the patient to roll away from you – ascites is
suggested if the note becomes resonant.
Check for fluid thrill Ask patient to position their hand in the
midline, and flick the abdomen to test for
transmitted thrill


Listen for bowel sounds Up to three minutes. Can be normal, absent

or tinkling (in obstruction)
Listen for bruits Aortic, renal, iliac, femoral

Final manoeuvres
Examine the ankles for oedema
Examine the hernial orifices (or say you
would, as below)

I would complete my examination by….

“I would like to examine the hernial orifices, examine the genitalia, perform a digital rectal
examination, dipstick the urine and look at the observation chart (temperature, BP, sats)”

Spider naevi – telangiectasia with a central arteriole from which radiate numerous small vessels. Found in the
distribution of the SVC, and due to hyperoestrogenic state in liver failure.
Leukonychia – whitening of the nails due to hypoalbuminaemia
Koilonychia – “spoon-shaped” nails due to iron deficiency
Dupuytren’s contracture – thickening of the palmar fascia, seen in relation to excess alcohol intake, DM,
epilepsy and hereditary.
Sister Mary-Joseph nodule – umbilical nodule due to metastatic cancer
Grey-Turner’s/Cullen’s signs – flank/periumbilical bruising seen in pancreatitis
Kayser-Fleischer rings – green-brown rings seen in the iris in Wilson’s disease
Fetor hepaticus – a musty-sweet smell found in liver failure
Angular stomatitis – cracks seen at the corner of the mouth, seen in iron deficiency
Leukoplakia – white tongue: smoke, spirits, sepsis, syphilis, sore teeth
Atrophic glossitis – a smooth tongue, seen in vit B12 and folate deficiency (amongst other things)
Acanthosis nigricans – velvety pigmented plaques in the axilla and back of the neck, seen in GI malignancy
(and several other conditions)