Abdominal Exam Steps

ABDOMINAL EXAM STEPS
1. Introduce yourself to the patient

“Hello, my name is your name. I am a your position and I would like to examine your
belly/tummy as well look at your hands, feet and face, is that ok? What is your name and age?”
2. Expose and position the patient

“Patient’s name, I want to be able to see your entire chest down to your hips as well as your
legs up to your knees. Can I lie you flat?”
Ask for a chair to sit at the level of the patient.
Remove patient’s shirt, pulls pants/undergarment down to expose inguinal area, expose calves
and feet and put down the head of the bed. (Assure the patient you will keep their genitals
covered)
3. General inspection from the foot of the bed

General body habitus: obese, wasted, pathognomonic of a particular disease e.g. chronic liver
disease etc. and what their abdomen looks like: distended, scaphoid, moving with respiration or
paradoxically
Are there adjuncts: nasogastric tube, Foley catheter and urine bag, vomit bowl, dialysis machine
4. Move to the right side for closer inspection of the abdomen and chest wall:
Look for scars, deformities, abnormal skin findings- spider naevi, gynecomastia, uremic frost
5. Inspect the hands:

Palmar side: pallor, Dupytren’s contracture, warmth/cold
Dorsal side: joint changes or finger shape
Nails: pallor, nail deformities in nutritional anaemias, clubbing
Assess for asterixis (flapping tremor) by asking the patient to hold the hand out with the fingers
spread “like you are stopping traffic”
6. Inspect the face:

Pull down eyelids for pallor, periorbital oedema
Pull up and ask to look down for sclera: icterus
Open mouth and look with penlight with tongue lifted for macroglossia, poor dentition, thrush,
look at palate
Look for parotid gland enlargement
7. Palpation of the abdomen:

Pull up a chair or stoop to the level of the belly
Ask if the patient is having any pain, and if so, to indicate where they are having it.
Tell them you are going to press on the belly now and begin with light palpation using the
palmar aspect of the fingers, flexing at the metacarpal joints in the 9 segments, starting farthest
away from the site of pain if indicated.
If a mass is found, characterize it using: site, shape, size, edges, surface, consistency,
tenderness, fluctuance, pulsatility and bruit assessment
Palpate more deeply in the same 9 segments.
8. Palpation of the liver:

Starting at the Rt iliac fossa, lay your hand flat with your thumb at right angles to your fingers
and use the radial border of the hand to anticipate the caudal movement of the liver in
inspiration.
Depress your hand in and superiorly and ask the patient to exhale moving in inch-wide
increments towards the Rt costal margin, each time asking the patient to “take a deep breath”
while assessing to see if the liver edge meets your hand.
If the edge is inferior to the costal margin, slid your hand over the edge onto the surface of the
liver and characterize the edge and surface.
9. Percussion of the liver span:

Start again at the iliac fossa and percuss in inch-wide increments up towards the Rt costal
margin until you reach the point of dullness. This is the lower boarder of the liver. Ask the
patient to mark that level by holding a finger there if they can.
Next, starting in the 2nd intercostal space- mid-clavicular line on the right, percuss down in the
intercostal spaces until you meet a dull percussion note- this is the superior border of the liver.
The distance between the two is the liver span.
10. Palpate for the spleen:

Start on the Rt iliac fossa again, this time directing the tips of your four fingers diagonally
towards the Lt subcostal region and using the similar see-saw manoeuvre, depress your fingers
and ask the patient to inhale to see if the lower margin of the spleen meets your hand.
Again move diagonally across and upwards in inch increments until you get to the Rt costal
margin. If no spleen edge palpated, ask the patient to roll onto their side towards you, with Lt
hand on your shoulder and while in that position, ask them to take inhale to see if you can tip
the spleen.
11. Percuss for the spleen

Allow the patient to lie back supine and go back to the Rt iliac fossa and percuss in the same
diagonal trajectory across to the Rt costal margin until the lateral thoracic wall looking for
dullness.
12. Assessment for ascites

Start with the first point of percussion in the patient’s midline over the umbilicus or point of
greatest distension. Percuss laterally towards you first assessing for a change from resonant to
dullness. Then go back to the midline and percuss away from you for the same.
At the point of dullness (if present), maintain your finger position and ask the patient to roll
towards you, wait 2 seconds and then percuss laterally towards you back to the patient’s
umbilicus from the Lt flank. When you get to the dullness in the lateral position, now ask the
patient to roll back into supine and wait 2 seconds. Percuss again to demonstrate recurrence of
the resonance.
If shifting dullness is present, then go on to demonstrate the fluid thrill
Ask the patient to press down firmly in the centre of their abdomen using the medial border of
their hand (you may place it there for them to help). Then with your non-dominant hand
depress the lateral flank bulge and make a distinct flick on the medial flank across from your
hand and feel for the fluid thrill, flick no more than twice.
13. Ballottement of the kidneys

Press your non-dominant hand into the abdomen just below the Rt costal margin, while sliding
your dominant hand parallel to it underneath the patient. Ask them to inhale and hold and
using a brink but similar motion for palpation, try to bounce the kidney towards your superior
hand. Do no more than 3 quick flicks
Repeat the same on the Lt side
14. Auscultate for bowel sounds and for renal artery bruits:
Change your stethoscope to the bell and listen over the ileocecal valve as well as the renal
arteries which are 2inces (5cm (laterally and cranially to the umbilicus. Palpate the femoral
pulse to adequately time the renal artery bruits.
15. Examine for the hernial orifices quickly.

“I just want to look down by your hips” and expose the inguinal regions.
Ask the patient to turn their head away and cough once, looking at the umbilicus and again
looking at the inguinal regions. If there is any bulge you may ask them to cough again with your
hand palpating for a cough impulse.
16. Check for pedal oedema

Ask if there is any pain, use the pulp (not tip) of the thumbs to depress against a bony
prominence and then slide over to detect a divot in the soft tissue, assess how high tit extends
by going up every 3 inches to the mid-thigh.
17. Ask to perform a rectal examination and examine the patient’s genitalia to complete your
examination
18. Thank the patient and cover them with the sheet.
To Do:
1. Create a classified list of causes of hepatomegaly
2. Create a classified list of causes of splenomegaly
3. Create a classified list of causes of balotteable kidneys
3. Discuss the investigative approach to a patient with ascites including imaging modalities,
abdominocentesis procedure and tests on ascetic fluid and supporting blood investigations.
Classify causes of ascites using the SAAG
4. Create a classified list of causes of cirrhosis and describe 10 clinical features of chronic liver
disease.

Abdominal Exam Steps

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ABDOMINAL EXAM STEPS

1. Introduce yourself to the patient

2. Expose and position the patient

3. General inspection from the foot of the bed

5. Inspect the hands:

6. Inspect the face:

7. Palpation of the abdomen:

8. Palpation of the liver:

9. Percussion of the liver span:

10. Palpate for the spleen:

11. Percuss for the spleen

12. Assessment for ascites

13. Ballottement of the kidneys

15. Examine for the hernial orifices quickly.

16. Check for pedal oedema

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