Abdominal Examination OSCE Guide

The abdominal examination involves examining the patient to pick up clinical signs suggestive
of underlying gastrointestinal disease. It frequently appears in OSCEs and this guide
demonstrates how to perform an abdominal examination in a systematic manner. A video guide
is included.

Introduction
Introduce yourself
Explain the examination
Gain consent
Expose patients chest & abdomen
Position patient flat with arms by side, legs uncrossed & head on pillow
Ask if patient has any pain anywhere before you begin!

General Inspection
Look around bedside for treatments or adjuncts - sick bowls, feeding tubes, stoma bags,
drains

Patients appearance in pain / agitated / confused?

Observation chart - note abnormalities e.g. pyrexia / hypotension / tachycardia etc

Body habitus healthy / obese/ low BMI / cachectic

Scars - midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy)

Jaundice - indicates likely liver disease cirrhosis / hepatitis

Anaemia - obvious pallor suggests significant anaemia - e.g. GI bleeding

Abdominal distention - ascites / bowel distension / large masses

Masses - may suggest malignancy / organomegaly

Dressings - may be covering wound sites

Tattoos / needle track marks have increased suspicion for blood borne viruses (e.g. Hepatitis
B/C)

Excoriations suggestive of pruritus - raised bilirubin

Inspection
Hands

Clubbing - can be a result of inflammatory bowel disease / cirrhosis / coeliac disease

Koilonychia - spooning of the nails chronic iron deficiency

Leukonychia - whitened nail bed hypoalbuminemia liver disease / malnutrition

Palmar erythema - reddening of palms thenar /hypothenar eminences liver disease /
pregnancy
Dupuytrens contracture - thickening of palmar fascia causing finger contracture ALD

Hepatic flap:

Ask patient to stretch out arms, with hands dorsiflexed & fingers stretched out
Ask to hold their hands in that position for 15 seconds
The hands with flap (flex/extend at the wrist) in an irregular fashion if positive
This sign can indicate either encephalopathy (due to liver failure) / uremia / CO2
retention

Arms

Bruising - may suggest abnormal coagulation (PT) due to liver failure

Petechiae - suggestive of thrombocytopenia - often platelets <20
Excoriations - suggests presence of itch (pruritis) - raised bile acids (cholestasis)

Axillae

Lymphadenopathy - may suggest metastatic malignancy / lymphoma

Hair loss - malnourishment / iron deficiency anaemia
Acanthosis nigricans (darkened pigmentation)- can be indicative of malignancy in the GI tract
Eyes

Ask patient to lower one of their eyelids with their finger. Inspect for the signs below.

Jaundice often first noted in the sclera - liver cirrhosis / biliary obstruction (gallstones,
malignancy)
Anaemia - conjunctival pallor suggests significant anaemia
Xanthelasma raised yellow deposits surrounding eyes - hyperlipidaemia

Mouth

Angular stomatitis - inflamed red areas at the corners of the mouth - iron/B12 deficiency
Oral candidiasis - white slough noted on oral mucous membranes iron deficiency /
immunodeficiency
Mouth ulcers - crohns disease / coeliac disease
Tongue (glossitis) smooth swelling of the tongue with associated erythema - iron/B12/folate
deficiency

Neck

Cervical lymph nodes - lymphadenopathy may indicate infection / metastatic malignancy

Virchows node - left supraclavicular fossa - suggestive of gastric malignancy

Chest

Spider naevi central red spot with reddish extensions (>5 significant) - chronic liver disease
Gynecomastia overdevelopment of male mammary glands - ALD/digoxin/spironolactone
Hair loss - malnourishment / iron deficiency anaemia

Close inspection of abdomen

Scars - midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy)
Masses - assess size, position, consistency, mobility lipoma / malignancy / organomegaly

Pulsation - a central pulsatile & expansile mass may indicate an abdominal aortic aneurysm
(AAA)

Cullens sign - bruising surrounding umbilicus retroperitoneal bleed (pancreatitis/ruptured

AAA)

Grey-Turners sign bruising in the flanks - retroperitoneal bleed (pancreatitis/ruptured AAA)

Abdominal distension - fluid (ascites) / fat (obesity) / faeces (constipation) / flatus / fetus
(pregnancy)
Striae - either reddish/pink (new) or white/silverish (chronic) abdominal distension
Caput medusae - engorged paraumbilical veins - portal hypertension
Stomas - Colostomy (LIF) / Ileostomy (RIF) / Urostomy (RIF, contains urine)
Palpation
Ask about the presence of any areas of pain (examine these last)

Look at patients face throughout the examination for signs of discomfort

Light palpation

Assess each of the four quadrants for the following

Tenderness - note the areas involved and the severity of the pain
Rebound tenderness - pain is worsened on releasing the pressure - peritonitis
Guarding - involuntary tension in the abdominal muscles - assess if localised or general

Masses large / superficial masses may be noted on light palpation

Deep palpation

Assess each of the four quadrants again, but with greater pressure on palpation

If any masses are noted, assess:

Location - which quadrant?

Size
Shape
Consistency - smooth / soft / hard / irregular
Mobility is it attached to superficial / underlying tissues?
Pulsatility - a pulsatile mass suggests vascular aetiology aneurysm

Liver

1. Start palpation in the right iliac fossa

2. Press your right hand into the abdomen as you ask the patient to take a deep breath

3. Feel for a step, as the liver edge passess below your hand

4. If you dont feel anything, repeat the process with your hand 1-2 cm higher
If you feel the liver edge, note the following:

Degree of extension below the costal margin

Consistency of the liver edge (smooth/irregular)
Tenderness - suggestive of hepatitis
Pulsatility - a pulsatile enlarged liver can be caused by tricuspid regurgitation

Gallbladder

The gallbladder is not usually palpable when healthy

An enlarged gallbladder suggests obstruction to biliary flow / infection (cholecystitis)

Perform palpation at the right costal margin, mid-clavicular line (9th rib tip)

If enlarged, a round mass, moving with respiration may be palpated - note any tenderness

Murphys sign

Place your hand in the area noted above

Ask the patient to take a deep breath
As the gallbladder is pushed down into your hand they may suddenly develop pain &
stop inspiring
This is a positive Murphys sign, which is suggestive of cholecystitis

Spleen

The spleen is not usually palpable, therefore if you feel it, its at least 3x its normal size!

1. Start in right iliac fossa as massive splenomegaly can extend this far!

2. Align your fingers in the same direction as the left costal margin

3. Press your right hand into the abdomen as you ask the patient to take a deep breath

4. Feel for a step, as the splenic edge passess under your hand (a notch may be noted) note
position

5. If you dont feel anything, repeat process with your hand 1-2 cm closer to the LUQ
Kidneys

1. Place your left hand behind the patients back at the right flank

2. Place your right hand just below the right costal margin in the right flank

3. Press your right hands fingers deep into the abdomen

4. At the same time press upwards with your left hand

5. Ask the patient to take a deep breath

6. You may feel the lower pole of the kidney moving inferiorly during inspiration

7. Repeat this process on the opposite side to assess the left kidney

Aorta

1. Palpate using fingers from both hands

2. Palpate just above the umbilicus at the border of the aortic pulsation

3. Note the movement of your fingers:

Upward movement = pulsatile

Outward movement = expansile (suggestive of AAA)

Bladder

An empty bladder will not be palpable (pelvic)

However an enlarged full bladder can be felt arising from behind the pubic symphysis

This may suggest a diagnosis of urinary retention

Percussion
Abdominal organs

Liver - percuss up from RIF then down from right side of chest to determine the size of the liver
Spleen percuss up from RIF moving towards the LUQ to assess for splenomegaly

Bladder - percuss suprapubic region - differentiating suprapubic masses (bladder (dull) / bowel
(resonant))
Shifting dullness

1. Percuss from the centre of the abdomen to the flank until dullness is noted
2. Keep your finger on the spot at which the percussion note became dull
3. Ask patient to roll onto the opposite side to which you have detected the dullness
4. Keep patient on their side for 30 seconds
5. Repeat your percussion in the same spot & then moving centrally
6. If fluid was present (ascites) then the area that was previously dull should now be resonant

Auscultation
Bowel sounds

Normal - gurgling
Abnormal tinkling in bowel obstruction
Absent ileus / peritonitis

Bruits

Aortic bruits - auscultate just above the umbilicus AAA

Renal bruits auscultate just above the umbilicus, slightly lateral to the midline

To complete the examination

Thank patient
Wash hands
Summarise findings

Say you would

Check hernial orifices

Perform a digital rectal examination (PR)

Perform an examination of the external genitalia

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