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.
2- 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:
whether they are comfortable at rest
do they appear to be tachypnoeic
are there any obvious medical appliances around the bed (such as patient controlled analgesia)
are there any medications around (although this is unlikely as all medications should be in a locked cupboard)
Each of these should be reported to the examiner.
3- Move on to examine the patient’s hands. You are looking for the presence of:
Koilonychia
Leukonychia
Nail clubbing
Palmar erythema
Nicotine staining
Dupuytren’s contracture
Koilonhychia
Clubbing
Leukonychia
Palmar erythema
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
4- 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.
5- Move on to examine the face. Initially check the conjunctiva for pallor which could be a sign of anaemia. 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 anaemia, as could angular stomatitis.
6- Move down to the neck to palate the left supraclavicular lymph node. 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.
7- Now move on to examine the chest. You should in particular look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology.
8- 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.
9- 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
10- Palpation of the abdomen should be performed in a systematic way using the 9 named segments of the abdomen:
