Lesson 5.4: Abdominal Examination
Patient position: lying flat, arms by sides, exposed from xiphisternum to pubic symphysis. Ask the patient to tell you if you cause pain throughout, and watch their face, not your hands, during palpation.
Technique Checklist
- General inspection — jaundice, pallor, cachexia, distension
- Hands — clubbing, leuconychia, palmar erythema, Dupuytren contracture, asterixis
- Arms — spider naevi (>5 significant), scratch marks
- Face — scleral jaundice, pallor, parotid enlargement, mouth ulcers
- Neck — Virchow node (left supraclavicular): screen for gastric cancer
- Chest — gynaecomastia, spider naevi, loss of axillary hair
- Abdomen inspection — distension, visible veins (caput medusae), hernias, scars
- Light palpation — all 9 regions; watch the patient's face for pain
- Deep palpation — all 9 regions systematically
- Liver — start in RIF, move toward RUQ
- Spleen — start in RIF, move toward LUQ
- Kidneys — bimanual balloting technique
- Percussion — liver borders, shifting dullness (ascites), suprapubic dullness
- Auscultation — bowel sounds, renal/aortic bruits
- Hernial orifices — inguinal, femoral, umbilical (with cough impulse)
- PR examination — describe you would perform if indicated; do not perform unless explicitly asked
- Bedside: urine dipstick, pregnancy test if relevant (say these aloud)
Key Examination Distinctions
When findings are handed to you, use these principles to interpret them:
- Liver (hepatomegaly): You cannot get above it. It moves with respiration. Dull to percussion. Starts in the right upper quadrant.
- Spleen: You cannot get above it. Moves diagonally toward the right iliac fossa. Has a palpable notch. Dull to percussion. Starts in the left upper quadrant.
- Kidney: You CAN get above it. Ballotable bimanually. Resonant (bowel overlies it).
- Ascites: Shifting dullness (fluid moves with the patient). Flanks dull, centre resonant. Fluid thrill if massive.
Detailed clinical causes of each finding (hepatomegaly in cirrhosis vs heart failure vs malignancy, etc.) are covered in the clinical case modules.