Introduction

1. Greet the patient and introduce yourself 
2. Confirm patient details
3. Briefly explain the examination in a patient friendly manner
4. Get patient consent
5. Set the head of the bed to a 45° angle 📐
6. Wash hands ✋
7. Expose patient’s abdomen and lower legs
8. Check the patient is not in any pain

General inspection of the patient

Identify any clinically relevant signs:

 Age: e.g. IBD more common diagnosis in younger patient whereas malignancy and chronic liver disease is more common in older patients

 Pain: examine the area where the pain is

 Confusion: end stage liver disease symptom

 Pallor: anaemia

 Jaundice: high bilirubin levels associated with liver pathology

 Scars: prior surgery

 Hyperpigmentation: darkening of the skin due to haemochromatosis

 Hernias: coughing can make them more visible

 Oedema: swollen limbs or abdomen due to liver cirrhosis

 Cachexia: muscle loss due to malignancy or advanced liver failure

Identify any objects or equipment that may be relevant:

 Prescriptions: recent medications 💊

 Mobility aids ♿

 Feeding tubes

 Fluid balance: indicate fluid overload or dehydration 

 Vital signs: reflect past and present clinical status 

 Surgical drains: record the type and location

 Stoma bag: record the location

 Other medical equipment

Hands

Inspection of hands

Inspect the palms ✋:

 Pallor: anaemia

 Dupuytren’s contracture

 Palmar erythema: red palm of hand, can indicate liver disease

Inspect the nails ✋:

 Leukonychia: hypalbuminaemia can cause the nail bed to whiten

 Koilonychia: anaemia can present with ‘spoon shaped’ nails

Assess for finger clubbing ✋:

1. Ask the patient to put the nails of their index fingers back to back
2. If you cannot see a diamond shaped window, the patient has ‘finger clubbing’

 The normal angle between the nail and the nail bed is lost due to soft tissue in the finger-tip swelling

 Can indicate: coeliac disease, IBD, lymphoma of the gastrointestinal tract and liver cirrhosis

Assess for Asterixis ✋:

1. Ask the patient to put both arms out in front of them, bending their hands backwards at the wrist joint and holding for 30 seconds
2. Observe for hand ‘flapping’

 Asterixis, or ‘flapping tremor’ is identified by the hands flapping

 Can indicate: hepatic encephalopathy, uraemia, or CO2 retention

Palpation of the hands

Assess the temperature:

 Symmetrical warmth indicates the patient is healthy

 Cold hands indicate poor peripheral perfusion ❄

Assess the radial pulse:

1. Use your middle and index fingertips to palpate 
2. Assess the rate and rhythm

Assess for Dupuytren’s contracture:

1. Palpate the palm
2. Identify thickened, ‘cord-like’ bands of palmar fascia

 The thickening of the palmar fascia, producing ‘cords’ will cause finger and thumb deformities

Arms and axillae

Inspect the arms:

 Needle track marks: indicative of intravenous drug use which can increase hepatitis risk

 Bruising: indicative of clotting abnormalities caused by liver disease

 Excoriations: scratch marks which may indicate cholestasis

Inspect the axillae:

 Hair loss: due to iron deficiency anaemia or malnutrition

 Acanthosis nigricans: thickened or darkened skin due to insulin resistance or gastrointestinal malignancy

Face

Inspect the eyes:

 Jaundice: visible in the upper region of the sclera

 Perilimbal injection: inflammation of the conjunctiva region adjacent to the iris, can be indicative of IBD

 Corneal arcus: white/grey/blue ring in the peripheral cornea, in patients <50 indicates hypercholesterolaemia

 Kayser-Fleischer rings

 Conjunctival pallor: indicates anaemia

 Xanthelasma: raised, yellow, cholesterol rich deposits on the area around the eye which indicate hypercholesterolaemia

Inspect the mouth:

 Oral candidiasis: fungal infection, identified by white mouth, caused by immunosuppression

 Hyperpigmented macules: polyps in the gastrointestinal tract caused by the genetic, Peutz-Jeghers syndrome

 Glossitis: enlarged tongue 👅, caused a deficiency in B12, iron and folate

 Aphthous ulceration: round or ovular ulcers on the mucosal membranes, which can also indicate B12, iron and folate deficiency

 Angular stomatitis: inflammation of the corners of the mouth caused by a variety of things such as iron deficiency

Neck

 Metastatic intrabdominal malignancy can be identified by a swollen Virchow’s node (left supraclavicular lymph node)

 Oesophageal cancer can be identified when the right supraclavicular lymph node is swollen

Palpate for lymphadenopathy:

 Palpate on both sides to identify swelling

Chest

 Hair loss: can be caused by increased oestrogen or malnourishment

 Spider naevi: lesions with a red centre and fine red lines extended from it ‘like a spider’, due to increased oestrogen levels, >5 indicate liver cirrhosis

 Gynaecomastia: male breast tissue enlarges due to increased oestrogen or medication such as digoxin/ spironolactone

Abdomen

 Hernias: assess for protrusions when coughing

 Scars: indicate previous surgery

 Striae: ‘stretch marks’ caused by rapid growth or skin stretching  

 Abdominal distension: caused by the 6F’s (foetus/faeces/fat/fluid/flatus)

 Cullen’s sign: bruising around the umbilicus indicates late stage pancreatitis

 Caput medusae: swollen paraumbilical veins and hypertension of the portal vein

 Grey-Turner’s sign: bruised flanks indicating haemorrhagic pancreatitis

Assess any stomas present:

 Contents: stool/urine

 Spout: no spout in ileostomies/urostomies, spout present in colostomies

 Location: indicates type of stoma (right iliac fossa = ileostomies and urostomies, left iliac fossa = colostomies)

Palpation of the abdomen

Prepare for palpation:

1. Lay patient flat on bed
2. Check for abdominal pain
3. Identify pain by watching their face when palpating

Light palpation:

Assess for signs of pathology as you lightly palpate the 9 abdominal regions:

 Masses

 Tenderness

 Guarding: involuntary tensing

 Rovsing’s sign: pain in right iliac fossa when palpating the left, can indicate peritonitis

 Rebound tenderness: slow compression and quick release of the abdominal wall causes pain which can indicate peritonitis

Deep palpation:

Apply more pressure and assess for signs of pathology as you palpate the 9 abdominal regions:

 Mobility: distinguish between superficial masses and those attached to other structures

 Location: record which region the mass is present

 Pulsatility: pulsatile masses, associated with vascular origins

 Consistency: smooth/soft/hard etc.

 Size/shape: approximately measure the size of the mass

Liver palpation:

1. Palpate the right iliac fossa as the patient inhales deeply to feel for the liver edge
2. Repeat, moving 1 to 2 cm upwards each time until you reach the right costal margin
3. If you identify the liver edge, record the following:
   • Position: greater than 2cm beneath the costal margin indicates hepatomegaly
   • Tenderness: can indicate hepatitis or cholecystitis
   • Consistency: if the liver edge feels nodular, it can indicate cirrhosis
   • Pulsatility: can indicate tricuspid regurgitation

Hepatomegaly causes:

 Hepatitis

 Leukaemia

 Haemolytic anaemia

 Wilson’s disease

 Glandular fever

 Hepatocellular carcinoma

 Primary biliary cirrhosis

 Hepatic metastases

 Haemochromatosis

 Myeloma

 Tricuspid regurgitation

Gall bladder palpation:

 If you can palpate the gall bladder, it suggests it is enlarged due to biliary flow obstruction/infection

1. Palpate at the right costal margin, in the mid-clavicular line
2. If you identify a motile round mass, it suggests the gall bladder is enlarged
3. Pain suggest cholecystitis (Murphy’s sign)
   1. Murphy’s sign is identified when you palpate the fall bladder as the patient inhales deeply and they suddenly stop mid-breath because they are in pain
4. No pain suggests pancreatic cancer

Spleen palpation:

1. Palpate the right iliac fossa as the patient inhales deeply to feel for the splenic edge
2. Repeat, moving 1 to 2 cm towards the left costal margin
3. If you identify the splenic edge, it is suggestive of splenomegaly

Splenomegaly causes:

 Glandular fever

 Haemolytic anaemia

 Portal hypertension caused by liver cirrhosis

 Splenic metastases

 Congestive heart failure

Kidney Balloting:

1. Place your left hand ✋ under the back, standing on the opposite side
2. Place your right hand ✋ just below the right costal margin
3. Push your right hand ✋ down and your left up as the patient inhales deeply
4. If you ballot the kidney, record its consistency and size
5. Repeat for the left kidney

Enlarged kidney causes:

 Unilaterally enlarged: renal tumour

 Bilaterally enlarged: polycystic kidney disease or amyloidosis

Aorta palpation:

1. Palpate just above the umbilicus in the midline using both of your hands
2. Record how your fingers move:
   1. Outwards: indicates expansile mass
   2. Superiorly: normal

 Further tests are require before diagnosis 

Bladder palpation:

1. Ask the patient to use the toilet before beginning
2. Palpate in the suprapubic area to identify if it is palpable and hence distended

Abdominal percussion

Liver percussion:

1. Percuss the right iliac fossa
2. Repeat, moving 1 to 2 cm towards the right costal margin until the percussion note becomes dull rather than resonant (indicates border of lower liver)
3. Continue to percuss upwards, 1 to 2 cm at a time until the percussion notes changes from dull to resonant (indicates upper liver border)
4. Approximate the size of the liver

Spleen percussion:

1. Percuss the right iliac fossa
2. Repeat, moving 1 to 2 cm towards the left costal margin, until the percussion note becomes resonant rather than dull (indicates location of spleen)
3. If you identify the spleen it is suggestive of splenomegaly

Bladder percussion:

1. Percuss in the midline of the umbilical region, moving downwards towards the pubic symphysis
2. When the percussion note becomes dull, you have identified the upper border of the bladder

Shifting dullness:

1. Percuss from the umbilical region, upwards towards the left flank
   1. A dull percussion note can indicate ascitic fluid in the flank
2. Ask the patient to role onto their side for 30 seconds ⏱ (keep your fingers in the position where the note became dull)
3. Repeat percussion, the percussion note should now be resonant to confirm ascites presence

Abdominal auscultation

Bowel sounds 👂:

Auscultate in ≥2  abdominal areas

 Normal bowel sounds: gurgling

 Absent bowel sounds: suggestive of ileus (malfunctioning peristalsis disrupts the intestine functioning)

 Tinkling bowel sounds: bowel obstruction

Bruit identification:

Identify vascular bruits (indicate turbulent blood flow) by auscultating over the aorta and renal arteries

 Aortic bruits: 1 to 2 cm above the umbilicus, can indicate abdominal aortic aneurysm

 Renal bruits: 1 to 2 cm above the umbilics, but slightly to the side of the midline on both sides, can indicate renal artery stenosis

Legs 

 Identify pitting oedema on the lower legs, can indicate hypalbuminaemia

Completion

1. Tell the patient the examination is complete, and thank them
2. Wash hands ✋
3. Summarise what the examination revealed

Summary:

1. Greet the patient and briefly explain the examination
2. Inspect the patient to identify any clinically relevant signs
3. Inspect the patient's arms, axillae, face and mouth
4. Palpate the neck for lymphadenopathy
5. Inspect the chest and abdomen for any clinical features
6. Assess any stomas present
7. Palpate, percuss and auscultate the abdomen
8. Assess for pitting oedema on the lower legs
9. Complete the examination by thanking the patient