Station 22 Abdominal examination 57
• Liver – Ask the patient to breathe in and out and, starting in the right iliac fossa, feel for the
inferior liver edge using the radial aspect of your index finger. Each time the patient inspires,
move your hand closer to the costal margin and press your fingers firmly into the abdominal
wall. The inferior liver edge may be felt as the liver descends upon inspiration, and can be
described in terms of regularity, nodularity, and tenderness.
• Gallbladder – Palpate for tenderness over the tip of the right ninth rib. Positive Murphy’s sign
(cholecystitis) is cessation of breathing on inspiration, and wincing, as the tender gallbladder
comes into contact with your fingers.
the tips of your fingers firmly against the abdominal wall so that your hand is pointing up and
leftwards. If the spleen is enlarged, the splenic notch may be ‘caught’ as the spleen descends
• Kidneys – Position the patient close to the edge of the bed and ballot each kidney using the
technique of deep bimanual palpation. Place one hand flat over the anterior aspect of the flank
(right hand for left kidney, left hand for right kidney), and press down whilst using the other
hand to push the kidney up from below.
Figure 16. Regions of the abdomen.
58 Station 22 Abdominal examination
• Aorta – Palpate the descending aorta with the tips of your fingers on either side of the midline,
just above the umbilicus. Pressing your fingers firmly into the abdominal wall, assess whether
the aorta is pulsatile and whether it is expansile, i.e. whether it causes the fingers of your right
• Liver – Percuss out the entire craniocaudal extent of the liver. In the mid-clavicular line, start
above the right fifth intercostal space and progress downwards. The normal liver represents an
area of dullness which typically extendsfrom the fifth intercostalspace to the edge of the costal
margin. Beyond this point, the abdomen should be resonant to percussion.
• Spleen – As for the liver, percuss the spleen to determine its size.
• Bladder – Percuss the suprapubic area for the undue dullness of bladder distension.
area of dullness is detected, keep two fingers on it and ask the patient to roll over onto his left.
After about 30 seconds, re-percuss the area which should now sound resonant. The change in
the percussion note reflects the redistribution of ascitic fluid under the effect of gravity.
other hand in an attempt to elicit a thrill.
• The mid-abdomen or ileocaecal valve for bowel sounds (Table 10). Listen for 30 seconds before
concluding that they are normal, hyperactive, hypoactive, or absent.
• The abdominal aorta for aortic bruits suggestive of arteriosclerosis or an aneurysm.
• 2.5 cm above and lateral to the umbilicus for renal artery bruits suggestive of renal artery
Table 10. Principal causes of altered bowel sounds
• Drugs such as anticholinergics and opiates.
• Paralytic ileus (absent bowel sounds).
Hyperactive • Diarrhoea of any cause.
• Mechanical bowel obstruction (high pitched bowel sounds).
• Cover up the patient and thank him. Enquire about and address any concernsthat he may have.
• Indicate to the examiner that you would normally test for pedal oedema, examine the hernia
orifices and the external genitalia, and carry out a digital rectal examination. You would also
• Summarise your findings and offer a differential diagnosis.
Station 22 Abdominal examination 59
Conditions most likely to come up in an abdominal examination station
• May result from alcoholic liver disease, viral hepatitis, right heart failure, haemochromatosis,
• Signs may include clubbing, palmar erythema, leukonychia, metabolic flap, hyperventilation,
bruising, jaundice, gynaecomastia, spider naevi, caput medusae, scratch marks, hepatomegaly,
ascites, pedal oedema, Dupuytren’s contracture (alcohol), tattoos (hepatitis C), signs of right
heart failure such as raised JVP and pedal oedema, bronzing of the skin (haemochromatosis),
Kayser–Fleischer rings (Wilson’s disease).
• Causes include portal hypertension (usually complicating liver cirrhosis), lymphoproliferative
and myeloproliferative diseases, haemolytic anaemias, and infections such as infectious
mononucleosis/glandular fever and malaria.
Specifications: A plastic model in lieu of a patient.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the procedure to him, emphasising that it might be uncomfortable but that it should
not be painful, and obtain his consent.
• Ask the patient to lower his trousers and underpants.
• Ask him to lie on his left side, to bring his buttocks to the side of the couch, and to bring his
knees up to his chest (Sims’ or left lateral recumbent position).
• Gently separate the buttocks and inspect the anus and surrounding skin. In particular, look out
forskin tags, excoriations, ulcers, fissures, external haemorrhoids, prolapsed haemorrhoids, and
• Lubricate the index finger of your right hand.
• Position the finger over the anus, as if pointing to the genitalia.
• Ask the patient to bear down so as to relax the anal sphincter.
• Gently insert the finger into the anus, through the anal canal, and into the rectum (Figure 17).
Scrotum Figure 17. Digital rectal
Station 23 Rectal examination 61
• Test anal tone by asking the patient to squeeze your finger.
• Rotate the finger so as to palpate the entire circumference of the anal canal and rectum. Feel
for any masses, ulcers, or induration and for faeces in the rectum. If there are any faeces in the
rectum, assess their consistency.
– in males, pay specific attention to the size, shape, surface, and consistency of the prostate
gland. Assess whether the midline groove is palpable
– in females, the cervix and uterus may be palpable
• Remove the finger and examine the glove. In particular look at the colour of any stool, and for
the presence of any mucus or blood.
• Remove and dispose of the gloves.
• Clean off any lubricant or faeces on the anus or anal margin.
• Give the patient time to put his clothes back on.
• Ensure that he is comfortable.
• Address any questions or concerns that he may have.
• Present your findings to the examiner, and offer a differential diagnosis.
Conditions most likely to come up in a rectal examination station
Benign prostatic hypertrophy (BPH):
• In BPH the prostate is enlarged in size (>3.5 cm) and slightly distorted in shape, but it is still
rubbery and firm, with a smooth surface and a palpable midline groove.
• In prostate carcinoma, the prostate is also enlarged and asymmetrical, but this time it is hard
and irregular/nodular and the midline groove may no longer be palpable.
in the groin is listed in Table 12.
Table 11. Principal differentiating features of indirect and direct inguinal and femoral hernias
Femoral hernia (below inguinal
• Neck of hernia is superior to
• Accounts for 80% of inguinal
• Neck of hernia is superior to
• Accounts for 20% of inguinal
• Higher incidence in females,
but still less common overall.
Femoral hernia Indirect inguinal hernia
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