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    General Inspection:

    • Introduction/privacy/consent/wash hands/name & age of patient/asks patient for sites of pain before commencing: Initiates examination by exposing adequately from xiphoid to pubic symphysis


    • Performs a general inspection: Asks patient to lift head whilst lying horizontal, subsequently observing for the presence of any herniations

    • Hands:

      • Assesses for palmar erythema, palmar creases (Addison's and anaemia) dupuytren's contractures, clubbing, koilonychias, leuconychia (low albumin), sweating (hyperthyroidism)

      • Assesses for a flapping tremor in liver failure (Mentions the need for a pulse check: anaemia, thyrotoxicosis)


    • Face:

      • Assesses for cheilitis, glossitis, fetor hepaticus, mucous membranes for hydration status & ulcers (IBD)

      • Assesses eyes for evidence of anaemia, jaundice of sclera, corneal arcus, xanthalesma & thyroid eye disease


    • Chest:

      • Assesses for stigmata of liver disease (spider naevi & gynaecomastia)


    • Abdomen:

      • Assesses for stigmata of liver disease; caput medusa, ascites. Obvious distension and scars. Evidence of itching from hyperbilirubinaemia. Presence of stationary, expansile or pulsatile masses (NB epigastric pulse is normal)



    • Student asks about areas of tenderness, and commences palpation away from that region if present

    • Superficial palpation initiated @ RIF assessing for voluntary & involuntary guarding

    • Deep palpation then initiated, assessing for rebound tenderness associated with generalised peritonitis. Student can ask patient to breath so that their abdomen touches their finger 2cm above normal level (unable to do so in peritonitis)

    • Student comments on expansile masses (AAA)

    • Palpates liver from RIF upwards, asking the patient to breath in as pushing upwards & deeply

    • Repeats above procedure for spleen, but moving in a diagonal manner from RIF to left hypochondrium

    • Ballots both kidneys to assess for polycystic kidney disease or enlarged kidneys associated with hydronephrosis



    • Student commences at the sides and moving medially. Test for shifting dullness for evidence of ascites

    • Tests for fluid thrill with patient holding hand in midline. This is positive only in severe ascites

    • Percusses liver margins from lower lobe of lung to above RIF


    • Assesses bowel sounds (absent in generalised peritonitis)

    • Assesses left of umbilical area for aortic bruit and lateral regions for renal artery stenosis

    • Assesses liver for bruits, associated with liver disease

    • Comments on potential succussion splash 4hrs after eating, to assess delayed gastric emptying

    • Examination completed by PR and examination of the hernial orifices


    Thanks patient & documents findings in the notes:

Author: Mr Adnan Darr MBCHB, BSc, MSc, MRCS  | Speciality: Examination  | Date Added: 10/10/2011


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