MRCS Abdominal examination

1. Introduction
• Wash hands.
• Introduce self to patient and gain consent -e.g. “Hello my name is ....... I am the
candidate pleased to meet you. Would it be ok if I examined you?”
• Ask for a chaperone.
• Ensure privacy, comfort, exposure and position (i.e. flat with one pillow).
• Ask the patient whether they have any pain and if so where?

2. Peripheral inspection/examination
• Note: if asked to examine the ‘Abdomen’ this may imply a directed examination of
the abdomen itself as opposed to ‘Abdominal system’ which would include peripheral
examination.
• Inspect from side of bed - look for IV infusions, charts, drainage devices etc.
• Hands:
• Leukonychia - white nails related to hypoalbuminaemia i.e. liver disease, poor
nutrition.
• Koilonychia - spoon-shaped nails associated with iron deficiency anaemia
• Digital clubbing - abdominal causes include: cirrhosis (particularly primary
biliary cirrhosis), ulcerative colitis, Crohn’s disease, coeliac disease.
• Terry’s lines - opaque nail with dark band on tip associated with liver disease.
• Palmar erythema - vasodilatation secondary to non-metabolised oestrogens
i.e. chronic liver disease.
• Dupuytren’s contracture - fixed flexion deformity of the hand due to fibrosis
of palmar fascia associated with liver disease (particularly alcoholic), diabetes,
repetitive trauma etc.
• Liver flap - ask patient to hold arms straight out and cock wrists back. Look
for coarse flap. Indicates hepatic encephalopathy Tip: whilst assessing for flap
take the patients pulse.
• Eyes:
• Pallor of conjunctiva - anaemia
• Icteric sclerae
• Mouth:
• Angular stomatitis - inflammation and fissuring at corners of mouth
associated with iron deficiency anaemia, B vitamin deficiency, infection,
mechanical irritation.
• Glossitis - inflamed tongue causes like as above. B12 deficiency (pernicious
anaemia) associated with ‘smooth beefy’ tongue.
• Aphthous ulcers - can be associated with Crohn’s disease.
• Central cyanosis
• Icteric palate
• Hepatic foetor
• Pigmented macules - Peutz-Jeghers syndrome.
• Telangiectesia - can be associated with hereditary haemorrhagic
telangiectasia.
• Supraclavicular nodes - Left supraclavicular lymphadenopathy = Virchow’s node can
be associated with abdominal malignancy (Troisier’s sign).
• Chest:
• Gynaecomastia - sign of poorly metabolised oestrogen.
• Spider naevi - >6 within the superior vena cava distribution can indicate portal
hypertension.
• Loss of axillary hair - sign of poorly metabolised oestrogen.
• Other:
• Scratch marks (jaundice), tattoos.
 MRCS Abdominal examination

3. Abdomen
3.1. Inspection
• Abdomen moving with respiration with no evidence of discomfort.
• Distension
• Masses
• Scars
• Fistula
• Stomas
• Tubes
• Hernias, divarification of recti - ask pt to lift head off from bed to accentuate.
3.2. Palpation
• Always clarify any pain and palpate the most tender region last.
• Light and then deep palpation of all nine quadrants - observing patient for sign of
pain.
• Liver - start in RIF, palpating on deep inspiration, up to the right upper quadrant.
• Spleen - start in RIF, palpating on deep inspiration, obliquely up to the left upper
quadrant.
• Kidneys - bimanual palpation.
• Aorta - palpate epigastrium for ‘pulsatile, expansile mass’ indicating possible aortic
aneurysm.
• Hernial orifices - palpate for cough impulse at deep inguinal ring.
3.3. Percussion
• Shifting dullness - indicating ascites.
• Percuss boundaries of liver and spleen.
• Look for percussion tenderness - sign of peritonitis.
3.4. Auscultation
• Bowel sounds - high pitched may indicate obstruction, silent abdomen could be
associated with peritonitis or obstruction.
• Renal artery bruits - either side of umbilicus.
• Femoral bruits.
• Liver bruits - can occur in hepatitis, arteriovenous malformations.
4. Further examinations/bedside tests
• Complete examination - groin, external genitalia, DRE and check for ankle oedema.
• Bedside tests - urine dipstick, full observations, fluid balance chart, stool chart.
5. Thank the patient
6. Summarise findings and plan for further investigation/
management.