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Basic Abdominal Examination Proforma

WIPPE

Wash hands

Introduce yourself

Permission from the patient to examine them

Position (completely flat with the abdomen exposed, pillow under head for comfort)

Exposure (ask patient to strip down to underwear, maintain patient dignity with
blanket)

Identify Patient (confirm the following details before starting)

Name

Age / date of birth

Date (so you can write your findings down in the notes and compare with previous
examinations)

Inspection

Start with a general inspection

o Does the patient look in pain?
o Is he/she comfortable?
o Is he/she fully aware of what is happening?
o Does the patient appear of normal colour (i.e. not Jaundiced etc)
o Overall build (BMI)
o Are there any indicative findings in the patients surroundings

Inspect the Hands

o

Nails Changes (Clubbing, Leuconychia, Koilonychia)

o Tar staining
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o Palmar Erythema
o Dupuytrens Contracture
o Purpura
o Liver flap

Clubbing

TIP:
Having a list of the causes of
clubbing ingrained in your
memory as this is often an
examiner (OSCE) and
consultant favourite

Schamroths Test is
something that some
examiners like to see you do
as it makes it obvious what
you are inspecting for. In
practice it may be easier to
inspect the nail bed angle
from side on.

Congenital Heart Disease

Lung Cancer

Ulcerative Colitis

Bronchiectasis

Bronchial Carcinoma

Infective Endocarditis

Neoplasias (mesothilioma)

Gastroninstestinal (cirrhosis/Coeliac disease)

Vitals:
o

Blood Pressure (In a medical school clinical examination setting you should
always offer this, though you may be asked to move on due to lack of time. In
a hospital setting this may often have been done on general obs of the
patient by ward staff.)
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o

Pulse (Rate & Rhythm)

Inspect the Arms

o Bruising
o Track lines
o Scratch marks (pruritus)
o Spider Naevi

Moving onto the face:

Inspect the Eyes

o Yellow Sclera (Jaundice)
o Pale Conjunctiva, Corneal Arcus (Anaemia)
o Xanthelasma (around the eyes)

Mouth
o Poor dentition
o Ulceration
o Angular Stomatitis

Lymph nodes Palpation (this can be done at any stage in the sequence but it makes most
logical sense to perform this here)

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Inspection of the Abdomen

Specific Abdominal Inspection

Gynaecomastia

Dilated Veins (Caput Medusae)

Bruising (Grey Turners/Cullens Signs)

Abdominal Distension

Visible masses (pulsatile?)

Visible peristalsis

Striae

Scars

Palpation
o With the patient positioned flat and the abdomen as relaxed as possible
begin palpation whilst standing on the right side of the patient. (TIP: if your
hands are cold, warm them up first! Or at least warn the patient before
starting)
o Start in the right iliac fossa and ensure you palpate each of the abdominal
regions.

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o Flexing the hip can aid abdominal relaxation. Conversely, asking the patient
to raise their head off the bed may promote accentuation of hernias (e.g.
umbilical), increasing ease of identification.
o Localise any areas of tenderness
o One hand for superficial palpation, then both hands can be used for deep
(specific organs or masses). During palpation hands should be flat on the
abdomen, try not to poke your fingers into the patient too aggressively.

Palpation of Specific Organs:

Palpation of the Liver

o Start in the right iliac fossa
o Flat of hand to be parallel to the costal margin
o Advance the hand upwards asking the patient to take deep breaths. (N.B.
This should be done in smaller steps than is shown in the basic abdominal
examination video).
o Feel for the lower border of the liver (Normally not palpable).

Palpation of the Gall Bladder

o

Tip of the right 9th rib corresponds to the fundus of gall bladder

If gentle and firm pressure in this area when the patient breathes in causes
tenderness and guarding in this area this is a positive Murphys sign

Palpation of the Spleen

o Enlarges towards the right iliac fossa; so start palpation from there
o For ease wrap left hand around the back and side of left lower rib to lift the
spleen anteriorly
o Point fingers towards the left axilla

Palpation of the Kidney

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o Palpate bimanually (Ballot the kidneys)

o For left kidney, tuck left hand up under the left flank and place the right hand
on the anterior abdominal wall opposite to the left hand. The aim is to trap
the kidney between both hands, remember it usually not palpable in a
healthy patient. Do the opposite of this for the right kidney.
o Enlargement of this organ can be differentiated from liver or spleen
as the kidney is less mobile on respiration and bimanually palpable

Percussion

Percuss in the main abdominal regions. Following this, specific organs may be
percussed:
o Liver: Assess the liver span by percussing from above and below the liver
o Spleen may be percussed
o Bladder may be percussed

Auscultation
o Look for the gurgling sound of intestinal peristalsis in the middle of abdomen
and note its frequency

Listen for at least 30 seconds before concluding absence of sounds

o Listen for renal artery bruits 2.5 cm above and lateral to the umbilicus
To conclude your examination you should:

Palpate inguinal lymph nodes

Examine the External Genitalia

Perform a PR examination

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Additional components not included in the video but should be understood and performed
if appropriate:

Test for shifting dullness (ascities)

o Percuss just to the left of the umbilicus (patient left) with your
fingers parallel to the midline and pointing towards the patients
feet. Reposition fingers laterally 2cms at a time until dullness is
elicited. Keep your fingers in this location and ask the patient to roll
towards you and wait. If positive, percussion in this region now will
elicit resonance as the fluid will have shifted with gravity.

Fluid Thrill
o Tapping on one side of abdomen would elicit thrill on a palm placed
flat on the opposite side. The patients palm may be placed vertically
on the umbilicus to dampen transmission of waves through the
subcutaneous fat tissue

Guarding

Rebound Tenderness (appendicitis)

Rosvings Sign (appendicitis)

Rigidity (in peritonitis)

Remember this is by no means an exhaustive list of every relevant sign or step in an

abdominal examination. However this should serve as a useful base for you to build on with
practice, experience and directed learning.

Example of how to present findings:

General introduction:
o

This is Kimothy Jenkins a 27 year old woman who presented with ........ On
examination I found....

Important Positive Findings

o List these off.... The patient had....
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Important Negative Findings

o

However, there was no.... (these should be those relevant to ruling out
differentials)

Clinical Conclusions
o

These findings are consistent with...

o Then be prepared to explain how you would like to proceed (investigations

and management etc.)

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