Abdominal examination and how to present it

The abdominal examination is the physical assessment of the abdomen and the systems that drain into or sit around it: the gut, liver, gallbladder, spleen, kidneys, bladder, major vessels and the body wall. It is done at the bedside to support or refute the working diagnosis, to decide who is sick, and to create a baseline for comparison later. A consultant urologist and a first-year student use the same sequence; they differ only in how much they hear in it. ^[2]

It is never a substitute for the history. The history decides what the abdomen might be; the examination decides whether the findings agree. Done in the wrong order, or in clothing, it misses things. Done well, it narrows a broad differential in thirty seconds.

Setting matters. A warm, quiet room, a bed at a height that protects your back, a sheet for warmth and dignity, and a patient who is not left shivering on a couch. Expose the abdomen from the xiphisternum to the pubic symphysis (waist to pubis in a young woman; the lower chest too if you might need to assess the liver or spleen). Ask about pain before you touch.

The student's aim is not to "do" the examination; it is to produce a short, accurate statement of what is there. That statement, not the sequence of tricks, is what the next clinician will act on.

Start the encounter like every other examination. Introduce yourself, confirm the patient's name and date of birth, explain in plain words what you are about to do and why, and ask consent. Hand hygiene before and after. Gloves if there are open lesions, stomas or body fluids. A chaperone for genital or rectal examination, and for any examination where either party prefers one.

Position the patient lying flat on the bed, arms by the sides and legs uncrossed, with the head of the bed raised to about 45 degrees so they can breathe and see you ^[1]. Warm your hands. Kneel or stand close enough that you are not reaching across the bed. Ask where the pain is and agree with the patient that you will leave that area until last.

Exposure should be honest rather than modest to the point of futility: from the waist up in most patients, lower legs visible so that peripheral oedema can be seen. Offer a blanket. Tell female patients they need not remove a bra unless the upper abdomen is involved.

Equipment you actually use: stethoscope, pen torch, tape measure. A blanket, a pillow to support the knees, and a sheet.

Work in the same order every time. Consistency is what makes you fast and accurate; it is also what makes you reliable when tired. The sequence below is the standard bedside one^[1].

1. Stand at the foot of the bed and look before you touch. Note approximate age, body habitus, nutritional state, distress or confusion, old scars, drains, stomas, tubes and medicines. In very thin patients the respiratory movement of the abdomen is visible; in obstruction the bowel may be seen moving.

2. Inspect the hands. Palmar erythema and Dupuytren contracture (thickened fibrous bands tethering the palmar fascia) are stigmata of chronic liver disease; koilonychia (spoon-shaped nails) suggests iron deficiency; clubbing appears in inflammatory bowel disease, cirrhosis and coeliac disease; asterixis (a flapping tremor elicited by dorsiflexing the wrists) appears in hepatic encephalopathy. Compare hand temperature and feel for asterixis early.

3. Inspect the eyes. Look for conjunctival pallor, scleral icterus (jaundice), corneal arcus, xanthelasma and the circumferential reddening of perilimbal injection. Kayser-Fleischer rings (a brown-green ring at the corneal limbus) point to Wilson disease. Jaundice in a patient with abdominal pain is a red flag.

4. Inspect the mouth. Angular stomatitis, glossitis, aphthous ulceration and oral candidiasis are common in iron, B12 and folate deficiency and in inflammatory bowel disease. A coated tongue is non-specific.

5. Examine the neck. Palpate the supraclavicular fossae, paying particular attention to the left (Virchow's node), which, when enlarged, can signal an abdominal malignancy draining via the thoracic duct.

6. Inspect the chest for spider naevi (central red papule with fine radiating vessels; more than five is more likely to be pathological, such as chronic liver disease), gynaecomastia and hair loss, all driven by increased circulating oestrogen, and for obvious respiratory distress. ^[1]

7. Inspect the abdomen. Ask the patient to cough and watch for protrusion through the wall. Look for scars (which map to past surgery), abdominal distension (fat, fluid, flatus, faeces, fetus or a large mass), caput medusae (engorged paraumbilical veins of portal hypertension), striae (tearing of skin in ascites, malignancy, Cushing syndrome, obesity, pregnancy), stoma characteristics, and the bruising of Cullen sign (periumbilical) and Grey-Turner sign (flanks), which are late signs of haemorrhagic pancreatitis.

8. Palpate lightly across all nine regions, pressing only a centimetre or so. Note tenderness and its location, voluntary guarding (the patient contracting the wall in response to pain), involuntary guarding or rigidity (the wall staying hard between your examinations, suggesting peritonitis), and masses. Rebound tenderness is said to be present when slow compression of the wall followed by sudden release produces sharp pain; it is non-specific and unreliable, suggestive at best of peritoneal inflammation ^[1]. Ask about pain again partway through and palpate any painful areas last, watching the patient's face throughout, since patients often do not volunteer discomfort.

9. Palpate deeply across all nine regions with greater pressure, warning the patient. For any mass, describe location, approximate size and shape, consistency, mobility (fixed or mobile) and whether it is pulsatile, since a pulsatile expanding mass in the midline raises the possibility of an abdominal aortic aneurysm. A visible cough impulse or a lump that appears on straining should be recorded.

10. Palpate the liver. Start in the right iliac fossa at the edge of the superior iliac spine and work in 1 to 2 cm steps towards the right costal margin. Ask the patient to inspire deeply as your hand rests; a step felt as the liver edge passes below the fingers suggests hepatomegaly at that level, and an edge palpable 1 to 2 cm below the costal margin can be normal. An edge more than 2 cm below the costal margin suggests hepatomegaly ^[1]. Record edge consistency (nodular suggests cirrhosis), tenderness (hepatitis, or the gallbladder you are also pressing) and pulsatility (tricuspid regurgitation).

11. Palpate the gallbladder at the right costal margin in the mid-clavicular line, near the tip of the ninth rib. A normal gallbladder is not palpable; a palpable, well-defined mass moving with respiration suggests obstruction or infection. Record tenderness (cholecystitis) versus a painless distended gallbladder (possible pancreatic malignancy).

12. Palpate the spleen with the same oblique stroke from the right iliac fossa towards the left costal margin, feeling for the splenic edge and its notch on inspiration. The spleen is not palpable in healthy people; palpable at the edge of the left costal margin suggests splenomegaly, which at that site implies enlargement to roughly three times normal size ^[1].

13. Ballot the kidneys by placing one hand behind the patient under the flank and the other below the costal margin in front, pressing the hands together while the patient inspires; the lower pole moving between the fingers is ballottement. Kidneys are not usually ballotable, though the inferior pole can sometimes be felt during inspiration in very thin patients ^[1]. Bilaterally enlarged ballotable kidneys suggest polycystic kidney disease or amyloidosis; a unilaterally enlarged one suggests a renal tumour.

14. Palpate the aorta with both hands just above the umbilicus in the midline. In health the hands move upward with each pulse; outward movement suggests an expansile mass such as an abdominal aortic aneurysm. This is a crude test and is not diagnostic.

15. Palpate the bladder after offering the toilet. A distended bladder rises from behind the pubic symphysis in the suprapubic area and may make the patient want to pass urine at once. In people who pass urine regularly it is not palpable.

16. Percuss the abdomen. Percuss upward from the right iliac fossa toward the right costal margin in 1 to 2 cm steps until the note becomes dull (lower liver border), then continue until it becomes resonant again (upper border), giving an estimate of liver size. Do the same on the left for the spleen, which is not identifiable by percussion unless enlarged. Percuss in the midline downward from the umbilicus for a dull bladder in retention. ^[1]

17. Assess shifting dullness for ascites. Percuss from the umbilical region to the left flank; if the flank is dull, keep your fingers on that spot, roll the patient onto the right side for about 30 seconds, and percuss again. If the previously dull area has become resonant, free fluid has shifted with gravity ^[1]. While the patient lies still, a fluid thrill may be sought by tapping one side of the abdomen while the other hand on the opposite side feels for the transmitted impulse; it is more likely to be genuine with a tense, large ascites.

18. Auscultate in at least two areas for bowel sounds (normoactive, high-pitched tinkling, or absent) and then listen over the renal arteries, iliac vessels and aorta for bruits. Do not let a stethoscope delay care in an acute abdomen, but record what you heard.

19. Examine the hernia orifices and external genitalia. Inspect the umbilicus, linea alba, groin scars and both groins at rest and during cough; an impulse on cough suggests a hernia. Palpate the superficial inguinal ring and the femoral canal if trained, with gloved hands and a chaperone. Inspect the scrotum and penis for swelling, infection, phimosis and testicular masses, and the vulva similarly where relevant. A hernia can strangulate; record tenderness and irreducibility.

20. Perform targeted signs only after the general examination. Eliciting Murphy sign means holding the fingers at the right costal margin in the mid-clavicular line as the patient inspires deeply; pain that halts inspiration mid-breath suggests cholecystitis ^[1]. Rovsing sign is said to be positive when palpation of the left iliac fossa causes pain in the right iliac fossa; it is not reliable and at best indicates peritoneal inflammation on either side ^[1]. Test for rebound tenderness and rigidity, and for percussion tenderness, where these add information. Note whether the patient lies still (peritonitis) or writhes (colic).

21. Rectal examination is not part of every abdominal examination, but it is part of the assessment of the acute abdomen, of rectal bleeding, of pelvic pain, and of constipation. With consent and a chaperone, inspect the perianal area, then palpate for stool, blood, masses, tenderness (in particular the right iliac fossa and the deep pelvis) and prostate size. Record what you felt and, just as importantly, what you did not feel.

22. Finish by helping the patient to dress, washing your hands and summarising what you found. Tell the patient what will happen next in words they understand.

A useful examination records signs, not opinions. Group findings by what they imply rather than by the order in which you found them.

Two common traps deserve emphasis. Rovsing sign, rebound tenderness and guarding are often written in notes as if they diagnosed appendicitis; they do not. They indicate peritoneal inflammation, and which side it is on can be guessed only after considering the whole picture. Equally, an absent bowel sound in a sick patient is more worrying than a tinkling one, because it suggests the gut has stopped rather than working against an obstruction.

Presentation is a separate skill from examination. The findings must be given in an order the listener can follow, without repeating yourself, and ending with a conclusion.

Start with the patient and the setting in one short line: age, sex, and that you examined the abdomen. Then give the positive findings in order of importance, not in the order you found them. State the negative findings that would have mattered (the abdomen is soft; no masses; no organomegaly; no jaundice; no spider naevi). Finish with one sentence that is your summary and your leading diagnosis, followed by the most important alternative.

Use the same order every time: general inspection, hands, abdomen, organ palpation, percussion, auscultation, hernias and targeted signs, then your conclusion. Leading with the abdomen itself is usually best, because that is what the listener is waiting for.

Words matter. Say "the liver edge is palpable 4 cm below the right costal margin, firm, non-tender, with a smooth edge" rather than "hepatomegaly". Say "there is shifting dullness to the left flank, consistent with ascites" rather than "ascites". Where a finding is an inference, label it as one: "suggesting", "consistent with", "in keeping with". Do not say "cirrhosis"; say "stigmata of chronic liver disease".

State negatives precisely and only those that matter. "No jaundice, no spider naevi, no palmar erythema, no ascites" tells the listener that chronic liver disease has been considered and not found. "No tenderness, no guarding, no rebound" does the same for peritonitis. Inventing negatives you did not look for is as bad as inventing positives.

End with two sentences. The first summarises the abnormal cluster in clinical language. The second gives the single most likely diagnosis and one or two close alternatives in order of probability, and names the urgent possibility if there is one. For example: "In summary, this is a middle-aged man with stigmata of chronic liver disease and hepatomegaly, but no ascites. The most likely cause is chronic liver disease with portal hypertension, although a focal hepatic lesion must be excluded, and I would expect liver function tests and an ultrasound."

For the written record, use the same headings as your spoken order and keep sentences short. Positive before negative within each line. Record measurements in centimetres below the costal margin at a stated point (right mid-clavicular line), masses by position, size, consistency, mobility and pulsatility, and sounds as heard. Record what you did not do and why (for example "rectal examination declined; patient in pain, not done at this time").

A written presentation then looks like a transcript of your spoken one without the fillers. If a senior can read the note and reconstruct what you saw, it is good enough.

Illustrative examples, using invented patients and findings; they are teaching illustrations, not real cases.

Normal abdomen (spoken). "A 23-year-old woman is comfortable at rest. She is not jaundiced and there are no spider naevi or palmar erythema. Her abdomen is soft and non-tender in all nine regions, with no guarding, no rebound and no masses. The liver is not palpable and the spleen is not palpable. There is no shifting dullness and no fluid thrill. Bowel sounds are normal and there is no hernia on coughing. In summary, the examination is normal; there is no evidence of liver disease, ascites or intra-abdominal pathology."

Chronic liver disease with hepatomegaly (spoken). "A 58-year-old man has palmar erythema, a bilateral Dupuytren contracture and six spider naevi on the chest. He is not clinically jaundiced. His abdomen is distended but soft and non-tender, with no guarding or rebound. The liver edge is palpable 5 cm below the right costal margin in the mid-clavicular line, firm and nodular, with a sharp edge. The spleen is palpable 3 cm below the left costal margin. There is shifting dullness to both flanks, consistent with ascites, but no fluid thrill. In summary, this man has stigmata of chronic liver disease with hepatosplenomegaly and ascites. The most likely diagnosis is cirrhosis with portal hypertension; I would also consider a focal hepatic lesion and would want liver function tests, coagulation and an ultrasound."

Splenomegaly (spoken). "A 34-year-old woman is not jaundiced and has no stigmata of liver disease. Her abdomen is soft and non-tender, with no guarding or rebound. The liver is not palpable. The spleen is palpable 6 cm below the left costal margin, firm and smooth, moving on inspiration, with a notch felt at its edge. There is no shifting dullness and no abdominal masses. In summary, isolated splenomegaly in an otherwise well woman. The most likely causes are lymphoproliferative or infectious (for example infectious mononucleosis) or portal hypertension from chronic liver disease despite the absence of stigmata; I would arrange full blood count, blood film, liver function tests and an abdominal ultrasound."

Acute abdomen (spoken). "A 26-year-old previously well man lies still and avoids moving. He is not jaundiced. His abdomen is not distended. There is marked tenderness and involuntary guarding in the right iliac fossa, with rebound tenderness and percussion tenderness, and Rovsing sign is positive on the left. The liver and spleen are not palpable and there is no shifting dullness. Bowel sounds are reduced. In summary, this is a young man with localised peritonitis in the right iliac fossa. The most likely diagnosis is acute appendicitis; close alternatives are a perforated Meckel diverticulum or mesenteric adenitis, and ectopic pregnancy must be excluded in any woman of childbearing age."

• Palpating the painful area first. It tenses the whole wall and ruins the rest of the examination; agree with the patient to leave it to last and watch the face, not only the fingers.
• Stopping at the abdomen. Hands, eyes, mouth, neck and chest take two minutes and change the diagnosis, especially for chronic liver disease.
• Not warming the hands, not relaxing the patient (a pillow under the knees releases the abdominal wall), or examining through clothing.
• Pressing too hard during light palpation, which obliterates a mass you have not yet found.
• Recording "soft abdomen" or "hepatomegaly" instead of where, how far, and what it felt like.
• Treating Rovsing, rebound and guarding as diagnoses rather than as evidence of peritoneal inflammation.
• Forgetting the groin, external genitalia and anus in a patient with pelvic or lower abdominal pain.
• Omitting the rectal examination because it is uncomfortable for you, or assuming it is always required when it is not.
• Calling the examination normal because you did not find anything, rather than because you looked everywhere.
• Palpating the aorta very firmly in a patient who might have an aneurysm; the test is gentle and clinical judgement comes first.
• Using the stethoscope as a delaying tactic in a peritonitic patient.

• A good abdominal examination is a sequence done the same way every time, ending in one clear statement.
• Preparation (consent, chaperone, hand hygiene, positioning at about 45 degrees, exposure, warmth) determines whether the rest is possible.
• Inspect before touching: general impression, hands, eyes, mouth, neck, chest and abdomen in that order.
• Palpate lightly first and deeply second; leave painful areas until last and watch the patient's face.
• Hepatomegaly is an edge more than 2 cm below the costal margin; the spleen is not palpable normally and is palpable at the left costal margin at roughly three times normal size.
• Ballot kidneys gently; ballotability alone is not abnormal, but enlarged kidneys are.
• Shifting dullness is the standard test for free ascites; wait about 30 seconds after rolling the patient.
• Rovsing sign and rebound tenderness are unreliable and only indicate peritoneal inflammation; guarding and rigidity are more meaningful.
• Murphy sign suggests cholecystitis; a positive is one that halts inspiration.
• Auscultation records bowel activity and vascular bruits; it should not delay treatment in an acute abdomen.
• Presentation leads with the most important finding, states the relevant negatives, then gives a summary and a short differential.
• Write as you would speak, in short sentences, with measurements and characteristics rather than labels.
• Include the rectal and groin examinations whenever the diagnosis calls for them.