- Wash hands
- Introduce yourself and ask permission
- Any pain?
- Position/Exposure: Lie flat, hands at sides, blanket to cover legs
- Examine from the patient’s right
Take your time to have a good look! In this station the diagnosis is often given away by careful initial inspection e.g. CLD, renal transplant etc.
- Stand back and look carefully, make this obvious to the examiner or state ‘I am just going to have a look from the end of the bed’
- Look for 3 main things from end of the bed
- Chronic liver disease (spider naevi, gynaecomastia, loss of hair, scratch marks, bruising)
- Decompensation of liver disease (ascites – distended abdomen, jaundice)
- Scars (hockey stick- renal transplant, multiple – could this be IBD?)
- For extra marks: Look for underlying cause:
Chronic liver disease
- Tattoos (Viral hepatitis)
- Needle prick marks
- Skin pigmentation (haemochromatosis)
- Xanthelasma (PBC)
- Obese (NAFLD)
- Bruising (lymphoproliferative disease)
- Jaundice (haemolytic anaemia e.g. hereditary spherocytosis)
- Rutherford Morrison ‘Hockey stick’ incision
- Nephrectomy scar (on back)- polycystic kidneys
- Needle prick marks on fingers (capillary glucose in diabetes)
- Malar rash (SLE)
- Examine nails for clubbing (chronic liver disease, IBD, coeliac), koilonychia (spoon shaped nails in iron deficiency anaemia), leuconychia (white nails-low albumin in CLD)
- Look at both hands for Dupuytren’s contracture, palmar erythema, spider naevi
- Feel both palms, early Dupuytren’s may be palpable as a nodular area in the palm.
- Check for Asterixis: Ask the patient to ‘place your arms out in front of you and cock your wrists back’. Asterixis is a course flapping tremor which is present in hepatic encephalopathy and thus, unlikely to be present in your exam.
- Ask to pull down one eyelid looking for anaemia, scleral icterus (jaundice seen in the eye)
- Look around the eye for xanthelasma (Primary biliary cirrhosis, NAFLD)
- Look briefly in the patient’s mouth for
- Smooth tongue, angular stomatitis (iron deficiency)
- Aphthous ulcers (IBD)
- Pigmented freckles (Peutz-Jeghers syndrome)
- Inspect for:
- Loss of male hair distribution
- Spider naevi: if present count them: more than 5 is abnormal.
- Ask the patient to lean forward: use opportunity to examine neck and supraclavicular fossae for lymphadenopathy: examine from Feel above the left clavicle for Virchow’s node (sign of intra-abdominal malignancy)
- Inspect the back for more spider naevi and look for scars e.g. nephrectomy incision in loin.
- Re-inspect more closely (this will give you time to think!). Think about what you have already found and what you would expect next. Look for
- Abdominal distension (ascites, constipation etc)
- Scars (Hockey stick: Renal transplant, Mercedes-Benz: Liver transplant, scars from laparoscopic surgery, drains etc)
- Caput medusae (Veins radiating from umbilicus- a sign of portal hypertension)
- Striae (‘stretch marks’): May be normal but if marked could represent Cushing’s syndrome (e.g. due to steroids used in IBD/renal transplant)
Superficial & Deep Palpation
Peritonism is indicated by: Rebound: Pain elicited on palpation is less severe than pain when hand rapidly removed from abdomen Guarding: Involuntary tensing of abdominal musculature due to local or generalised inflammation
- Looking at the patient’s face, warn the patient (ask again if any pain) and gently palpate (using the flat of your hand) in all 9 areas, starting away from any painful area and working towards it. You are looking for evidence of pain and peritonism (guarding, rebound)
- Palpate more deeply for any masses (try to think what this might be: where is it, how does it feel (smooth, hard, craggy), is it attached to surrounding structures etc. (see ‘examination of a lump)
- If there is a ‘hockey stick’ incision: feel for an underlying mass (the kidney transplant).
- Place the flat of your hand on the right lower quadrant with the index finger side of your hand towards the patient’s head.
- Ask the patient to take deep breaths in and out.
- Move up the abdomen towards the right costal margin. Feel as the patient breaths in, move up as they breath out
- If there is liver enlargement you will feel the liver moving under your fingers.
- Quantify the enlargement with ‘number of finger breadths’ below the costal margin.
- Try to feel if it is smooth or craggy.
- Confirm the enlargement by percussing from RIF up to right costal margin. The liver will be dull to percussion.
In advanced cirrhosis, the liver may not be palpable as it shrinks with time- do not be disheartened!
- With the same technique and starting in the right iliac fossa, slowly move diagonally to the left costal margin feeling for a spleen.
- Use a flat hand but the tips of your fingers, rather than the margin of your index finger.
- If the spleen is palpable, then it is
- Features of the spleen (to distinguish from kidney):
- You can not get above it
- Dull to percussion
- Moves with respiration
- Splenic notch
- Confirm the enlargement but percussing in the same direction.
- If impalpable when lying flat, ask the patient to lean onto their right hand side and palpate deeply in LUQ.
- Percuss from the midline to the patient’s left side – moving left will make the next stage easier!
- If ascites is present, the resonance in the midline will be come dull laterally
- If dull, ask the patient to lean to their right side while keeping your finger in position.
- Wait 20s, then percuss. If the previously dull area is now resonant, this is shifting dullness, and a sign of abdominal fluid (ascites)
- While patient is still in position (on right side), place your left hand behind them onto their back and ask them to roll flat.
- Using your right hand palpate deeply in the mid-left side of the abdomen
- Ballot the left kidney by pressing sharply upwards with your left hand (on their back), an enlarged kidney will be palpable on balloting.
- Perform the same manoeuvre to palpate for the right kidney.
- Listen for bruits:
- Abdominal aortic aneurysm: just above umbilicus
- Renal 2.5cm above and lateral to umbilicus (renal artery stenosis)
- Bowel sounds (listen in right lower quadrant, ‘over the ileocaecal valve’)
‘I would like to dipstick the urine, examine the external genitalia and perform a digital rectal examination’.
NB: This is the standard suggested completion sentence. This can be adapted if necessary to the condition in question. For example, for a renal transplant you may wish to ask to ‘dip the urine for protein, check the blood glucose and to know the blood pressure.’