Examination Notes by Idunn Morris
Abdominal System Examination
1. Introduction and orientation; name, role and consent.
2. Develop rapport (& wash hands in warm water).
3. Ask patient if they have any pain or tenderness anywhere
4. Appropriately expose the patient (from xiphisternum to pubis) and lay them
flat (pillow for head only – unless severe SOB) with hands by their sides.
5. General inspection;
a. Surroundings.
b. General appearance –colour (jaundice), obvious pain / SOB.
6. Examination of the hands;
a. Clubbing (liver cirrhosis, IBD – Crohn’s / Ulcerative Colitis, coeliac’s
disease – malabsorption, GI lymphoma).
b. Tendon xanthomata (fatty deposits in tendons - hyperlipidaemia)
c. Anaemia (check palmar creases for colour).
d. Palmar Erythema (mottled, bright-red cutaneous vasodilatation over
thenar and hypothenar eminences, often normal, suggestive of liverdysfunction).
e. Leuconychia (hypoalbuminaemia, chronic liver disease).
f. Blue half-moons (hepatolenticular degeneration; Wilson’s disease).
g. ‘Half and Half’ nails (chronic renal failure).
7. Check for asterixis (flapping tremor of hepatic encephalopathy characterised
by jerky, irregular flexion-extension movements at the wrist and
metacarpophalangeal joints, often accompanied by lateral movements of the
fingers).
8. Examination of the radial pulse unilaterally.
9. Check both forearms for AV fistula suggesting dialysis (using the back of
your hand to feel for a thrill over the fistula site).
10. Blood pressure.
11. Examination of the head & neck;
a. General;
i. Cushing’s syndrome; Moon face (buccal fat pads obscure the
ears from the front view).
ii. Nephrotic syndrome; Periorbital puffiness, dullness, lassitude.
iii. Renal failure; Grayish, sallow pallor.
iv. Rubor; hypertension, alcoholism, gastric carcinoid. (NB.
vscular fine purple malar rash can be seen with ileal carcinoid
metastatic to the liver).
b. Eyes;
i. Corneal arcus (cholesterol crystals in periphery of cornea. In
young associated with hypercholesterolaemia, association
weakens with age –arcus senilis).
ii. Xanthelasma (hyperlipidaemia).
iii. Anaemia (bottom eyelid).
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Examination Notes by Idunn Morris
iv. Jaundice (sclera – haemolysis / liver disease).
c. Mouth; (remove dentures, use a torch and wooden tongue depressor).
i. Cracked lips; suggestive of vitamin deficiency.
ii. Gums; spongy, bleeding and pigmentation.
iii. Ulceration; Crohn’s disease.
iv. Central cyanosis; (under the tongue).
d. Lymph; (check for lymphadenopathy – infection / Ca. –e.g. renal ca.).
i. Preauricular – in front of the ear.
ii. Postauricular – behind the ear.
iii. Occipital – base of the skull.
iv. Tonsilar – at the angle of the jaw.
v. Submandibular – under the jaw, lateral.
vi. Submental – under the jaw, medial.
vii. Superficial (Anterior) Cervical – superficial & anterior to the
SCM muscle.
viii. Supraclavicular – in the angle of the SCM muscle and the
clavicle.
12. Inspection of abdomen & chest;
a. Gynaecomastia (growth of breast tissues in males – high levels of
circulating oestrogen – drug-induced or chronic liver disease).
b. Abdominal symmetry
c. Surgical scars (vertical – general access; subcostal – gall bladder;
suprapubic – bladder / prostate / gynaecology; McBurney’s – appendix;
inguinal – hernia).
d. Surgical stomas (R iliac fossa – ileostomy; L iliac fossa – colostomy),
laproscopy scars (below umbilicus).
e. Peristaltic waves (L rib margin, across midline to the R of the midline).
f. Caput medusa (dilated collateral veins radiating from the umbilicus as
a result from cirrhosis and portal hypertension)
g. Ascites (bulging flanks).
h. Striae e.g. Cushing’s syndrome).
i. Hernia.
j. Spider naevi (telangiectases that consist of a large arteriole from
which radiate numerous small vessels – occur in upper part of body
only – more than two is abnormal).
k. Distended veins.
l. Masses.
13. Palpation of abdomen; (confirm no pain, make sure patient is relaxed,
observe patient’s face throughout procedure).
a. Light / superficial palpation;
i. Tone; light dipping movements over symmetrical areas,
commencing at point remote form the site of any pain.
ii. Report any tenderness or guarding.
iii. Mention rebound tenderness.
b. Deep palpation;
i. Use flat of hand (avoid fingertips – induces muscular
resistance; start away from site of tenderness).
ii. Feel for masses or organomegally.
c. Liver;
i. Place hand flat on abdomen with fingers pointing upwards.
Position the sensing fingers lateral to the rectus so that the
fingertips lie on a line parallel to the expected liver edge. Start
palpation from transumbilical plane.
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Examination Notes by Idunn Morris
ii. Press hand firmly inwards and upwards. Keep it steady as
patient takes a deep breath through the mouth.
iii. At height of inspiration, release inwards pressure on hand
while maintaining upward pressure –tips
d. Gall bladder;
i. Place examining fingers over the gall bladder area and ask
patient to take a deep breath in. Inspiration may be sharply
arrested with tensing of the abdominal muscles because of a
sudden accentuation of pain suggesting acute cholecystitis
(Murphy’s sign).
e. Spleen;
i. Place examining hand on ant. Abdominal wall with the
fingertips well below the L costal margin, pressing inwards and
upwards.
ii. Ask patient to breathe in deeply. If the spleen is significantly
enlarged, it will bump against the fingertips.
iii. At the height of inspiration, release the pressure on the
examining hand so that the fingertips slip over the lower pole of
the spleen, confirming its presence and surface characteristics.
iv. If the spleen is not palpable, move the examining hand
upwards after each inspiration until the fingertips are under the
costal margin.
v. Repeat this process along the entire rib margin as the position
of the enlarging splenic tip is variable.
vi. If still not palpable, position the patient in the R lateral position
with the L hip and knee flexed and repeat examination.
vii. Alternatively, examine the patient from the L side, curling the
fingers of the examining hand under the L costal margin as the
patient breathes in deeply.
f. Kidneys;
i. Use a bimanual technique to palpate (ballot) the kidneys.
ii. Place one hand posteriorly below the lower rib cage and the
other over the upper quadrant.
iii. Push the two hands together firmly but gently as the patient
breathes out.
iv. Feel for the lower pole moving down beneath the hands as the
patient breaths in deeply.
v. Push the kidney back and forwards between the two (balloting).
It helps to confirm that the structure being palpated is the
kidney.
vi. Assess the size, surface and consistency of a palpable kidney.
vii. Examine the L kidney from either side.
g. Abdominal Aortic Aneurysm (AAA);
i. Palpate AA for a laterally bounding pulse.
14. Percussion of abdomen;
a. Deduction of further organomegally;
i. Lightly for superficial structures (e.g. lower border of the liver),
more firmly for deeply placed structures (e.g. upper border of
the liver or bladder).
ii. Examine the spleen with the patient holding the breath during
full inspiration (percuss both below and then above the L costal
margin).
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Examination Notes by Idunn Morris
b. Shifting dullness;
i. Supine; percuss from the centre of abdomen, lateral into the
flank until a dull note is obtained. Mark this level.
ii. Roll the patient onto their other side (opposite from that
percussed) and pause for at least 10secs.
iii. Ascites is suggested if note becomes resonant and confirmed
by obtaining a dull note while percussing back towards the
umbilicus.
c. Fluid thrill;
i. Place hand on patient’s flank, flick the patient’s abdominal wall
skin over the other flank (using thumb or forefinger).
ii. If a fluid thrill or impulse is felt, repeat procedure with patients
hand placed along the abdominal midline sagittal plane to
dampen any possible thrill transmitted via the abdominal wall.
15. Auscultation of abdomen;
a. Bowel sounds in the 4 quadrants, noting frequency and loudness
(listen for at least 3mins before deciding they are absent).
b. Aortic and renal bruits.
c. Succussion splash elicited by placing the hands over the lower ribs
and shaking the patient quickly and rhythmically from side-to-side.
16. Examination of hernial orifices;
a. Inspect inguinal and femoral region upon patient standing.
b. Ask patient to cough (again observing).
c. Invaginate the scrotum with the little finger and gently palpate the
external inguinal ring and posterior wall of inguinal canal for possible
muscular defects.
d. Feel for impulse on coughing – if hernia present determine if reducible
by massage.
17. End pieces;
a. Examine rectum and external genitalia.
b. Perform urinalysis.
c. Ask for temperature (vital stats).
18. Wash hands
19. Write up findings in the notes and discuss findings / next step with patient.
Note
These notes were written by Idunn Morris, as a medical student in 2008. They are presented in
good faith and every effort has been taken to ensure their accuracy. Nevertheless, medical
practice changes over time and it is always important to check the information with your clinical
teachers and with other reliable sources. Disclaimer: no responsibility can be taken by either the
author or publisher for any loss, damage or injury occasioned to any person acting or refraining
from action as a result of this information
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