Abdominal OSCE Examination

Contents

1. Introduction
2. General Inspection
3. Hands and Arms
4. Face and Mouth
5. Neck and Chest
6. Inspection of the Abdomen
7. Palpation
8. Percussion
9. Auscultation
10. Examination of the Legs
11. Completing the Examination
12. Quiz

Introduction

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail in language the patient can understand.

Position the patient lying flat (supine) on the bed with a single pillow under their head and their arms by their sides and legs uncrossed, so the abdominal muscles relax. The head of the bed may initially be raised to around 45^o for the general inspection, but the patient should lie flat for palpation.

Expose the patient from the nipple line to the pubic symphysis, maintaining the patient’s dignity by only exposing the abdomen when you are ready to examine it.

Ask the patient if they have any pain anywhere before you begin, and watch their face for discomfort throughout, particularly during palpation.

General Inspection

Stand back and observe the patient and their surroundings from the end of the bed. This first impression is often more revealing than any individual manoeuvre.

Assess whether the patient looks comfortable or is in distress. A patient who is lying very still and resists movement may have peritonitis, as movement worsens the pain of an inflamed peritoneum, whereas a patient who is writhing and unable to get comfortable is more typical of colicky pain such as renal or biliary colic. Note also whether the patient seems alert or confused, as drowsiness or disorientation in a patient with liver disease can be an early sign of hepatic encephalopathy.

Look at the patient’s overall colour and build. Jaundice gives a yellow tinge to the skin and sclerae and suggests liver disease or biliary obstruction. Pallor may indicate anaemia, which in a gastrointestinal context could reflect chronic blood loss (for example from a malignancy or peptic ulcer) or malabsorption. Cachexia (profound muscle and fat wasting) raises concern about malignancy or malabsorptive disease such as coeliac disease.

Look for obvious abdominal distension, which has several causes often remembered as the ‘five Fs’: fluid (ascites), flatus (obstruction), faeces (constipation), fetus (pregnancy) and fat. Note any visible masses, hernias or pulsation.

Scan the bedside for clues: a stoma bag, surgical drains, a urinary catheter, feeding tubes, sick bowls, and any medications or fluids being administered. These objects tell you a great deal about the patient’s underlying condition and current management before you have laid a hand on them.

Hands and Arms

Take the patient’s hands and inspect them carefully. Chronic liver disease in particular produces a cluster of recognisable hand signs.

Look at the nails. Koilonychia (spoon-shaped nails that are concave and brittle) is a sign of chronic iron deficiency anaemia, which may result from gastrointestinal blood loss or malabsorption. Leukonychia (whitening of the nail bed) reflects hypoalbuminaemia, as a low serum albumin – produced by the liver – is seen in chronic liver disease and protein-losing states. Clubbing (loss of the normal angle between the nail and nail fold) in a gastrointestinal context may be caused by inflammatory bowel disease, coeliac disease, liver cirrhosis or gastrointestinal lymphoma.

Image - Koilonychia (spoon-shaped nails). This concave nail deformity is associated with chronic iron deficiency anaemia

Creative commons source by CHeitz [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Image - Finger clubbing, with loss of the normal angle between the nail and nail fold. In a gastrointestinal context it points to inflammatory bowel disease, coeliac disease, cirrhosis or lymphoma

SimpleMed original

Note any tar staining of the fingers, a yellow-brown discolouration that points to smoking – a risk factor for several gastrointestinal cancers, peptic ulcer disease and Crohn’s disease.

Inspect the palms for palmar erythema, a reddening of the heel of the palm caused by the altered sex hormone metabolism and high circulating oestrogen levels of chronic liver disease (it can also be a normal finding in pregnancy). Look for Dupuytren’s contracture, a thickening of the palmar fascia that draws the fingers (classically the ring finger) into fixed flexion; this is associated with alcohol excess and therefore with alcoholic liver disease.

Assess the temperature of the hands and the capillary refill time as a quick measure of peripheral perfusion. A refill time of greater than two seconds may indicate poor perfusion, such as in shock from gastrointestinal haemorrhage or sepsis.

Ask the patient to hold their arms out straight and cock their wrists back for 15–30 seconds to check for asterixis (a flapping tremor). In the context of an abdominal examination this is a sign of hepatic encephalopathy, where the failing liver cannot clear nitrogenous waste such as ammonia, which then disrupts brain function. It can also be caused by carbon dioxide retention and uraemia.

While at the arms, assess for bruising, excoriations (scratch marks) and needle track marks. Easy bruising reflects impaired synthesis of clotting factors by the diseased liver, while excoriations result from the intense itch (pruritus) caused by bile salts deposited in the skin in cholestasis. Track marks over the veins suggest intravenous drug use, an important risk factor for blood-borne viral hepatitis (hepatitis B and C) and its long-term complications of cirrhosis and hepatocellular carcinoma.

Face and Mouth

Move to the face and examine the eyes. Gently pull down the lower eyelid to inspect the conjunctiva, then ask the patient to look upwards while you inspect the sclera above the iris.

Look for conjunctival pallor, where the normally pink inner surface of the lower eyelid appears pale, indicating anaemia. Inspect the sclerae for jaundice (scleral icterus), a yellow discolouration that is often visible in the eyes before it is apparent in the skin. Jaundice reflects a raised serum bilirubin and may be pre-hepatic (haemolysis), hepatic (liver cell damage) or post-hepatic (biliary obstruction).

Around the eyes, look for xanthelasma (raised yellow cholesterol-laden plaques on the eyelids) and corneal arcus (a pale ring around the iris), both of which reflect hyperlipidaemia and can accompany cholestatic liver disease such as primary biliary cholangitis. Rarely, in Wilson’s disease, copper deposition produces brownish Kayser-Fleischer rings at the edge of the cornea.

Image - Jaundice of the sclera. The yellow discolouration reflects a raised serum bilirubin and is often visible in the eyes before the skin

Public Domain Source by unknown author [Public domain]

Ask the patient to open their mouth and inspect it. Angular stomatitis (cracked, inflamed corners of the mouth) and glossitis (a smooth, swollen, erythematous tongue) are signs of iron, vitamin B12 or folate deficiency, which may arise from malabsorption. Look for oral candidiasis (white plaques) and aphthous ulceration, the latter being associated with inflammatory bowel disease and coeliac disease. Note the general state of hydration by inspecting the mucous membranes for dryness. As you do so, note any fetor hepaticus – a sweet, musty smell on the breath caused by the build-up of nitrogenous waste in advanced liver failure, which often accompanies hepatic encephalopathy.

Neck and Chest

Examine the cervical and supraclavicular lymph nodes. A palpable, hard, enlarged left supraclavicular node is known as Virchow’s node (and the finding as Troisier’s sign), and is a classic marker of gastric malignancy, as the thoracic duct draining the abdomen empties near this node.

Inspect the chest and upper abdomen for spider naevi – central red arterioles with radiating small vessels that blanch on pressure to the centre and then refill outwards. They occur in the distribution of the superior vena cava (above the nipple line) and, like palmar erythema, are caused by the high oestrogen levels of chronic liver disease. More than five spider naevi is considered abnormal in an adult. Also note gynaecomastia and loss of body hair in men, which reflect the same hormonal disturbance.

Image - A spider naevus, with a central arteriole and radiating vessels. Multiple spider naevi in the superior vena cava distribution suggest chronic liver disease

Creative commons source by Herbert L. Fred, MD and Hendrik A. van Dijk [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Inspection of the Abdomen

Lower the bed so the patient is lying flat and kneel or crouch beside them so that your eyes are level with the abdomen. Inspecting tangentially in this way makes subtle masses, distension and pulsation far easier to see.

Look for scars, which give away the patient’s surgical history – for example a midline laparotomy scar, a right iliac fossa scar (appendicectomy), a small right subcostal (Kocher) scar (open cholecystectomy) or laparoscopic port scars. Identify any stoma and note its position and contents, as the site offers a clue to its type (a right iliac fossa stoma with a spout is usually an ileostomy, a left iliac fossa flush stoma usually a colostomy).

Note any distension, visible masses or obvious organomegaly. Look for caput medusae – distended veins radiating from the umbilicus – which forms when portal hypertension forces blood through collateral veins in the abdominal wall. Note any striae (stretch marks): silvery-white striae are common after pregnancy, weight change or with ascitic distension, while broad purple striae point to Cushing’s syndrome or steroid use. Inspect the flanks for bruising: Grey Turner’s sign (flank bruising) and Cullen’s sign (periumbilical bruising) suggest retroperitoneal haemorrhage, classically in severe acute pancreatitis.

Ask the patient to cough and watch the hernial orifices and any scars for bulging, which may reveal a hernia. Finally, look for visible peristalsis or pulsation; a prominent central pulsation may represent an abdominal aortic aneurysm.

Image - An ileostomy. A spouted stoma in the right iliac fossa producing liquid effluent is typically an ileostomy, whereas a flush stoma in the left iliac fossa is usually a colostomy

SimpleMed original

Palpation

Before touching the abdomen, ask again about pain and watch the patient’s face throughout. Kneel beside the patient so your hand approaches the abdomen flat, and keep your forearm horizontal.

Divide the abdomen mentally into nine regions (or four quadrants) and palpate each in turn, beginning away from any area of reported pain. Perform light palpation first, using the flat of your hand and assessing for tenderness, guarding (reflex tensing of the abdominal muscles) and any obvious masses. Involuntary guarding and rigidity indicate peritonism. Rebound tenderness – pain that is worse on suddenly releasing pressure than on pressing – and pain on coughing are further signs of peritoneal inflammation.

Follow with deep palpation to characterise any masses, noting their site, size, shape, consistency, tenderness and whether they are pulsatile. Always describe a mass in relation to the nine regions of the abdomen.

Now palpate the individual organs:

• Liver – begin in the right iliac fossa and move your hand upwards towards the right costal margin, asking the patient to take a deep breath in with each step so the descending liver edge meets your fingers. A palpable liver edge below the costal margin suggests hepatomegaly, the causes of which include congestion (right heart failure), infiltration (malignancy, fatty liver) and infection (hepatitis).
• Gallbladder – palpate at the right costal margin in the mid-clavicular line. A palpable gallbladder is abnormal. Test for Murphy’s sign by resting your fingers here and asking the patient to breathe in; if the inflamed gallbladder descends onto your hand and the patient catches their breath in pain, the sign is positive and suggests acute cholecystitis (it should be negative on the left). Bear in mind Courvoisier’s law: in a jaundiced patient, a palpable, non-tender gallbladder makes gallstones an unlikely cause and points instead to malignant obstruction of the biliary tree, such as a pancreatic head tumour.
• Spleen – start again in the right iliac fossa and move diagonally towards the left costal margin, as a spleen enlarges towards the right iliac fossa. The spleen has a notch and moves with respiration. Splenomegaly may be caused by portal hypertension, haematological disease or infection.
• Kidneys – ballot each kidney bimanually, with one hand in the flank posteriorly and the other anteriorly, pushing upwards to feel for the kidney moving between your hands on inspiration. Enlargement may indicate polycystic kidney disease, hydronephrosis or a tumour. A key distinction in the OSCE is that the spleen is dull to percussion, has a notch and you cannot get above it, whereas the kidney is resonant (overlying bowel), can be balloted and you can get above it.
• Aorta – place both hands either side of the midline above the umbilicus. A normal aortic pulsation is forward only, while an expansile (outward-pushing) pulsation that moves your hands apart suggests an abdominal aortic aneurysm.

Percussion

Percussion helps confirm the size of organs and detect free fluid.

Percuss the liver to define its upper and lower borders. Begin in the right lower chest and percuss downwards; the note changes from resonant (lung) to dull (liver), and percussing up from the abdomen identifies the lower edge. This confirms true hepatomegaly and avoids mistaking a hyperinflated chest (which pushes the liver down) for an enlarged liver.

Percuss the spleen over the left lower ribs; dullness here supports splenomegaly. Percuss suprapubically for a distended bladder, which is dull when full and is a common cause of a lower abdominal mass and discomfort.

Assess for ascites by testing for shifting dullness. Percuss from the umbilicus out towards the patient’s left flank; if you reach an area of dullness, keep your finger there and ask the patient to roll onto their right side. Wait a few seconds for the fluid to redistribute and percuss again – if the previously dull area has become resonant, this confirms free fluid that has shifted with gravity. Ascites most commonly results from portal hypertension in cirrhosis, but also from malignancy, heart failure and hypoalbuminaemia.

Auscultation

Place the diaphragm of the stethoscope on the abdomen and listen for at least 30 seconds before concluding that sounds are absent.

Assess the bowel sounds. Normal bowel sounds are intermittent gurgles. Tinkling, high-pitched bowel sounds are associated with mechanical bowel obstruction, where fluid and gas are forced through narrowed bowel under tension. Absent bowel sounds (after listening for a full period) suggest ileus or, in the context of a rigid tender abdomen, peritonitis.

Listen for bruits. An aortic bruit just above the umbilicus may indicate aneurysmal or atherosclerotic disease, and renal bruits lateral to the midline may suggest renal artery stenosis. Over the liver, a bruit can rarely be heard with hepatocellular carcinoma or alcoholic hepatitis.

Examination of the Legs

Inspect and palpate the lower limbs for pitting oedema by pressing firmly over the shin or ankle for a few seconds. In a gastrointestinal context, peripheral oedema commonly reflects the low serum albumin (hypoalbuminaemia) of chronic liver disease or protein-losing states, as the reduced oncotic pressure allows fluid to leak into the tissues. It may also accompany the fluid overload of right heart failure.

Completing the Examination

Thank the patient, ensure they are comfortable and re-cover them, then wash your hands.

Summarise your findings clearly and state whether the examination was normal or abnormal.

To complete the examination, state that you would perform an examination of the external genitalia and hernial orifices, a digital rectal examination, and examine the cardiovascular and respiratory systems if indicated. You would also perform relevant bedside tests including a urine dipstick, a set of observations and a blood glucose, and request appropriate investigations such as blood tests (full blood count, urea and electrolytes, liver function tests, amylase and clotting), and imaging such as an abdominal ultrasound or CT as guided by the clinical picture.

Quiz

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