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Abdominal Examination - OSCE Guide - Geeky Medics

The document provides a detailed guide to performing a systematic abdominal examination, including inspection, palpation, percussion, and auscultation of the abdomen. The examination is broken down into sections examining the general appearance, hands, arms, axillae, eyes, mouth, neck, chest, and close inspection of the abdomen. Specific techniques are described to palpate the liver, gallbladder, spleen, kidneys, aorta, and bladder. Percussion methods include assessing organ size and detecting shifting dullness.

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Jahangir Alam
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2K views9 pages

Abdominal Examination - OSCE Guide - Geeky Medics

The document provides a detailed guide to performing a systematic abdominal examination, including inspection, palpation, percussion, and auscultation of the abdomen. The examination is broken down into sections examining the general appearance, hands, arms, axillae, eyes, mouth, neck, chest, and close inspection of the abdomen. Specific techniques are described to palpate the liver, gallbladder, spleen, kidneys, aorta, and bladder. Percussion methods include assessing organ size and detecting shifting dullness.

Uploaded by

Jahangir Alam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Abdominal examination - OSCE Guide | Geeky Medics

3/4/15, 7:41 PM

ABDOMINAL EXAMINATION OSCE GUIDE


The abdominal examination frequently appears in OSCEs and this guide
demonstrates how to perform the examination in a systematic manner, with an
included video guide.
Introduction
Wash hands
Introduce yourself
Check patient details - name / DOB
Explain the examination
Gain consent
Expose patients chest & abdomen
Position patient on the bed, sat upright for the first part of the examination
Ask if the 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

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Dressings - may be covering wound sites infection / bleeding


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 will flap (flex/extend at the wrist) in an irregular fashion if positive
This sign can indicate either encephalopathy (due to liver failure) / uraemia / 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

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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

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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
Position the patient laying flat, with their arms by their side & legs
uncrossed
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)

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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

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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!

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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

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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 the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present (ascites) then the area that was previously dull should now be
resonant
Auscultation
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Bowel sounds
Normal - gurgling
Abnormal e.g. tinkling (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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