Abdominal (GI) Examination

Steps
1. Wash your hands, introduce yourself to the patient and clarify their identity.
Explain what you would like to do and obtain consent.  A chaperone should be offered for this
examination.

o Wash your hands

o Introduce yourself to the patient

 The patient should initially be laid on the bed and exposed from the waist up. Begin
by making a general inspection of the patient from the end of the bed. You should be looking
for:
o whether they are comfortable at rest

o do they appear to be tachypnea

o are there any obvious medical appliances around the bed (such as patient

Each of these should be reported to the examiner.

 Move on to examine the patient’s hands. You are looking for the presence of:

o Koilonychia

o Leukonychia

o Nail clubbing

o Palmar erythema

o Nicotine staining

o Dupuytren’s contracture

Ask the patient to hold their hands out in front of them looking for any signs of a tremor.
Them to extend their wrists up towards the ceiling keeping the fingers extended and look for
a liver flap.

o Inspect the patient's hands

o Inspect for clubbing

o Leukonychia

o Nail clubbing

o Dupuytren's contracture

 Now is a good time to assess the radial pulse. There is some argument as to whether
this should be performed or not in an abdominal exam; however, it can be a good indication
of sepsis or thyroid disease.
 o Take the radial pulse

 Move on to examine the face.

Initially check the conjunctiva for pallor which could be a sign of anemia.

Check the sclera for jaundice.

Next move to the mouth asking the patient to open it. Look at the buccal mucosa for any
obvious ulcers which could be a sign of Crohn’s disease.

Also look at the tongue. If it is red and fat it could be another sign of anemia, as could angular
stomatitis.

o Inspect the eyes

o Inspect the mouth and tongue

A palpable enlarged supraclavicular (Virchow’s) node is known as Troisier’s Sign. This is the
node which drains the thoracic duct. This receives lymph drainage from the entire abdomen as
well as the left thorax. Enlargement of this node may therefore suggest metastatic deposits
from a malignancy in any of these areas.

o Palate the left supraclavicular lymph node

 Now move on to examine the chest.

You should in particular look for gynecomastia in men and the presence of 5 or more spider
naevi. These are both stigma of liver pathology.

Spider nevus

 At this point ask the patient to lie as flat as possible with their arms straight down
beside them and begin your inspection of the abdomen. Comment on any obvious
abnormalities such as scars, masses and pulsations. Also note if there is any abdominal
distension.

 Unlike other examinations, auscultation for bowel sounds may be carried out before
percussion and palpation due to adverse effect that these procedures may have on the sound
 from the bowels. Listen with the diaphragm next to the umbilicus for up to 30 seconds. High
pitched or absent sounds may indicate bowel obstruction. Absence of sounds may be also be
caused by peritonitis.

Auscultation for bowel sound

 Palpation of the abdomen should be performed in a systematic way using the 9

o right and left hypochondrium,

o right and left flank,

o right and left iliac fossa,

o the umbilical area,

o the epigastrium

o and the suprapubic region.

Where you start depends on the patient. If a patient has pain in one particular area you should
start as far from that area as possible. The tender area should be examined last as they may
start guarding making the examination very difficult.

Thorax and abdomen

 Initial examination should be superficial using one hand. Place the hand flat over
each area and flex at the metacarpophalangeal joints. You should feel whether the abdomen is
soft but you should always be looking at the patient’s face for any signs of pain. If you feel
any abnormal masses you should report these to the examiner.
 o Flex at the metacarpophalangeal joints

 Once all 9 areas have been examined superficially, you should move on to examine
deeper.

A deeper exam is performed with two hands, one on top of the other again flexing at the MCP
joints. You should still be looking at the patient’s face for them flinching due to pain. Again,
examine all 9 named segments of the abdomen.

 Having performed a general examination of the abdomen, you should now feel for
organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and spleen
is similar, both starting in the right iliac fossa. For the liver, press upwards towards the
right hypochondrium. You should try to time the palpation with the patient’s breathing-in as
this presses down on the liver. If nothing is felt you should move towards the costal
margin and try again.

A distended liver feels like a light tap on the leading finger when you press down. If the liver
is distended, its distance from the costal margin should be noted.

o Palpate for the liver

o Front of abdomen
 Palpating for the spleen is as for the liver but in the direction of the
left hypochondrium. The edge of the spleen which may be felt if distended is more nodular
than the liver.

Another way to assess for splenomegaly is to ask the patient to lie on their right side.  Support
the rib cage with your left hand and again ask the patient to take deep breaths in moving your
right hand up towards the left hypochondrium.

o Palpating for the spleen

 To feel for the kidneys you should place one hand under the patient in the flank
region and the other hand on top. You should then try to ballot the kidney between the two
hands. In the majority of people the kidneys are not palpable, but they maybe in thin patients
who have no renal pathology.

o Feel for the left kidney

o Feel for the right kidney

 Palpate for the bladder by starting at the umbilicus, move in steps downwards
towards the pubic bone
 o Palpating for the bladder

 Next you should percuss. This can be also be used to check for organomegaly if it is
suspected. Percussion over the abdomen is usually resonant; over a distended liver it will be
dull. Percussion can also be used to check for ‘shifting dullness’ – a sign of ascites.

With the patient lying flat, start percussing from the midline away from you. If the percussion
note changes, hold your finger in that position and ask the patient to roll towards you. Again
percuss over this area and if the note has changed then it suggests presence of fluid such as in
ascites.

A distended bladder will also be dull to percussion and this should be checked for.

o Percuss for shifting dullness 1

o Percuss for shifting dullness 2

 You should also palpate for the abdominal aorta to check whether it is expansile,
which could be suggestive of an aneurysm.  Note that the aortic pulsation can often be felt in
thin patients, but shouldn’t be expansile.
 o Palpating for the abdominal aorta

 At this point, you should mention to the examiner that you would like to finish the
procedure with an examination of the hernial orifices, the external genitalia and also a rectal
examination. It is also appropriate to perform a urinalysis at this point including a pregnancy
test in females.

 Allow the patient to dress and thank them.  Wash your hands and report any
findings to your examiner.
 Kidney Examination
Introduction:
 Greets the patient
 Introduces him/herself
 Explains his/her role
 Washes his/her hands
 Explains the procedure to the patient
 Takes permission
 Appropriately exposes the area being examined
 Approaches from the right side of the patient
Bimanual palpation of the kidney:
 Asks if the patient has any pain or discomfort
 Approaches the patient from the respective side of each kidney, or at the right side.
 The patient lies on his back, with his/her legs flexed
 Places one hand (left in the case of right kidney and right in the case of left kidney) on the
lumbar region posteriorly below the rib cage and the other hand anteriorly
 The patient is asked to relax his abdomen by taking deep breaths
 The lower hand presses the loin upwards while the upper one pushes the anterior abdominal
wall backwards and inwards
 Note: Palpable kidney is pushed backward and forward between the two hands, a procedure
called “Balloting”
Murphy’s renal punch: (Costovertebral angle tenderness)
 The patient is asked to sit with his/her back towards the examiner
 Places non-dominant hand on the left costo-vertebral angle.
 Uses the thumb of the dominant hand to “punch” over your left hand.
 Repeat for the other side.

Bladder examination:
 Note: The bladder normally cannot be examined unless it is distended above the symphysis
pubis.
 On palpation, the dome of a distended bladder feels smooth and round.
 Percuss midline of the abdomen below the umbilicus towards the symphysis pubis to
determine how high the bladder rises above the symphysis pubis.
End:
 Covers the exposed area of the patient
 Thanks the patient
 Appendicitis
A. Psoas Sign:
o How to elicit?
While patient is in the supine position, place your hand just above the patient’s
right knee and ask him to actively flex his thigh against resistance exerted by the
examiner.
o What is a positive response?
The sign is positive when the patient reports increased abdominal pain.

B. Rovsing's Sign:
o How to elicit?
While patient is in the supine position, press deeply and evenly in the left lower
quadrant, then quickly withdraw your fingers.
o What is a positive response?
Patient reports pain in the right lower quadrant.

C. Obturator Sign:
o How to elicit?
While patient is in the supine position, flex the right knee and hip. Then the
patient’s ankle is held with one hand and the patients’ knee is held with the other
hand. Then the examiner rotates the hip internally by moving the ankle away from
the patient’s body and allowing the knee to move inward.
o What is a positive response?
The sign is positive when the patient reports right hypogastric pain upon internal
rotation of the hip.

Cholecystitis
B. Murphy’s Sign:
o How to elicit?
Ask the patient to breathe out and then hook the fingers of your right hand below
the costal margin on the right upper quadrant lateral to the right rectus muscle.
Then, ask patient to breathe in deeply.
o What is a positive response?
The sign is positive when the patient reports sharp increase in tenderness in the
right upper quadrant upon inspiration and with a sudden stop in inspiration.
 Oral Exam Checklist
Introduction:
1. Greets the patient.
2. Introduces yourself and role.
3. Confirm patient Identity.
4. Wash your hands, dry them and warm them.
5. Explains the procedure to the patient.
6. Takes permission from the patient.
7. Stand on the right side of the patient.
Required Equipment:
1. Tongue depressor
2. Light Source

Inspection: Use a torch to ensure good lighting, and use a tongue depressor when needed to
better visualize the oral structures, as demonstrated in the video link below.
1. Lips
a. Inspect landmarks – vermilion zone, commissures, nasolabial fold
b. Inspect color (e.g. cyanosis, jaundice, pallor)
c. Inspect surface for ulcerations, blisters, growths, thickness changes
2. Buccal mucosa – have patient open mouth wide in order to inspect.
3. Palate
a. Inspect color of hard and soft palate and inspect for ulcerations, thickenings, exudates, petechiae.
4. Tongue – inspect in normal resting position and in a protruded position.
a. Inspect color and texture of dorsal, ventral and lateral surfaces. Look for plaques, ulcerations, thickenings, changes in
papillae
b. Evaluate movement of tongue
5. Floor of the Mouth – have patient open their mouth and raise their tongue to the roof of their mouth to inspect the floor.
a. Inspect for color and texture changes (e.g. cyanosis, jaundice, pallor)

Palpation:
1. Submandibular Gland
a. Palpate over the parotid and submandibular glands (which should NOT be visible at their
normal size). Note the consistency as well as any enlargement or tenderness.
2. Tongue
a.
Ask the patient to stick out their tongue. Using a piece of gauze, grab the tongue with your
right hand and pull it to the patient's left. Palpate the right side of the tongue for any
nodules, tenderness, or hardening. Repeat for left side.
b. Using a tongue depressor, the tongue can be pushed down to better visualize the pharynx.
The tongue depressor should be placed on the middle third of the tongue. The tongue is
depressed and scooped forward behind the front teeth.
3. Floor of Mouth
a. Slide your right index finger under their tongue and palpate the floor of the mouth.
b. Simultaneously place your left index & middle fingers under the person's chin and palpate
upwards.
c. Note & describe any thickening, masses, induration or tenderness.