Abdominal Examination

Question 1

Give a GI cause of confusion

Answer 1

Confusion: often a feature of end-stage liver disease, known as hepatic encephalopathy.

Question 2

What is the following clinical sign and what does it suggest?

Answer 2

Abdominal distention: may suggest the presence of ascites or underlying bowel obstruction and/or organomegaly.

Question 3

What is the following clinical sign and what does it suggest?

Answer 3

Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. gastrointestinal bleeding or malnutrition). It should be noted that healthy individuals may have a pale complexion that mimics pallor.

Question 4

What is the following clinical sign and what does it suggest?

Answer 4

Jaundice: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer).

Question 5

What is the following clinical sign and what does it suggest?

Answer 5

Hyperpigmentation: a bronzing of the skin associated with haemochromatosis.

Question 6

What is the following clinical sign and what does it suggest?

Answer 6

Oedema: typically presents as swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated with liver cirrhosis in the context of an abdominal examination OSCE station.

Question 7

What is the following clinical sign and what does it suggest?

Answer 7

Cachexia: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly associated with underlying malignancy (e.g. pancreatic/bowel/stomach cancer) and advanced liver failure.

Question 8

What is the following clinical sign and what does it suggest?

Answer 8

Hernias: may be visible from the end of the bed (e.g. umbilical/incisional hernia). Asking the patient to cough will usually cause hernias to become more pronounced.

Question 9

Describe what you see in the image and its contents

Answer 9

Stoma bag(s): note the location of the stoma bag(s) as this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, whereas ileostomies are usually located in the right iliac fossa).

Question 10

Describe what you see in the image and its contents

Answer 10

Surgical drains: note the location of the drain and the type/volume of the contents within the drain (e.g. blood, chyle, pus).

Question 11

Describe what you see

Answer 11

Feeding tubes: note the presence of feeding tubes (e.g. nasogastric/nasojejunal) and whether the patient is currently being fed.

Question 12

What is the following clinical sign and what does it suggest?

Answer 12

Palmar erythema: a redness involving the heel of the palm that can be associated with chronic liver disease (it can also be a normal finding in pregnancy).

Question 13

What is the following clinical sign and what does it suggest?

Answer 13

Dupuytren’s contracture involves thickening of the palmar fascia, resulting in the development of cords of palmar fascia which eventually cause contracture deformities of the fingers and thumb. There are a number of factors that have been associated with the development of Dupuytren’s contracture including genetics, excessive alcohol use, increasing age, male gender and diabetes.

Question 14

What is the following clinical sign and what does it suggest?

Answer 14

Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).

Question 15

What is the following clinical sign and what does it suggest?

Answer 15

Leukonychia: whitening of the nail bed, associated with hypoalbuminaemia (e.g. end-stage liver disease, protein-losing enteropathy).

Question 16

What is the following clinical sign and what does it suggest?

Answer 16

Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in an abdominal OSCE station include inflammatory bowel disease, coeliac disease, liver cirrhosis and lymphoma of the gastrointestinal tract.

Question 17

What is the following clinical sign and what does it suggest?

Answer 17

Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of an abdominal examination, the most likely underlying cause is either hepatic encephalopathy (due to hyperammonaemia) or uraemia secondary to renal failure. CO2 retention secondary to type 2 respiratory failure is another possible cause of asterixis.

Question 18

What is the following clinical sign and what does it suggest?

Answer 18

Bruising: may suggest underlying clotting abnormalities secondary to liver disease (e.g. cirrhosis).

Question 19

What may excoriations suggest ?

What may needle track marks suggest?

Answer 19

Excoriations: scratch marks that may be caused by the patient trying to relieve pruritis. In the context of an abdominal examination, this may suggest underlying cholestasis.

Needle track marks: important to note as intravenous drug use can be associated with an increased risk of viral hepatitis.

Question 20

What is the following clinical sign and what does it suggest?

Answer 20

Acanthosis nigricans: darkening (hyperpigmentation) and thickening (hyperkeratosis) of the axillary skin which can be benign (most commonly in dark-skinned individuals) or associated with insulin resistance (e.g. type 2 diabetes mellitus) or gastrointestinal malignancy (most commonly stomach cancer).

Question 21

What may hair loss indicate?

Answer 21

Hair loss: loss of axillary hair associated with iron-deficiency anaemia and malnutrition. i

Hair loss can also be caused by increased levels of circulating oestrogen.

Question 22

What is the following clinical sign and what does it suggest?

Answer 22

Conjunctival pallor: suggestive of underlying anaemia.

Question 23

What is the following clinical sign and what does it suggest?

Answer 23

Jaundice: most evident in the superior portion of the sclera (ask the patient to look downwards as you lift their upper eyelid).

Question 24

What is the following clinical sign and what does it suggest?

Answer 24

Corneal arcus: a hazy white, grey or blue opaque ring located in the peripheral cornea, typically occurring in patients over the age of 60. In older patients, the condition is considered benign, however, its presence in patients under the age of 50 suggests underlying hypercholesterolaemia.

Question 25

What is the following clinical sign and what does it suggest?

Answer 25

Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.

Question 26

What is the following clinical sign and what does it suggest?

Answer 26

Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues (including the liver causing cirrhosis).

Question 27

What is the following clinical sign and what does it suggest?

Answer 27

Perilimbal injection: inflammation of the area of conjunctiva adjacent to the iris. Perilimbal injection is a sign of anterior uveitis, which can be associated with inflammatory bowel disease. Other clinical features of anterior uveitis include photophobia, ocular pain and reduced visual acuity.

Question 28

What is the following clinical sign and what does it suggest?

Answer 28

Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency (e.g. gastrointestinal malignancy, malabsorption).

Question 29

What is the following clinical sign and what does it suggest?

Answer 29

Glossitis: smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).

Question 30

What is the following clinical sign and what does it suggest?

Answer 30

Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.

Question 31

What is the following clinical sign and what does it suggest?

Answer 31

Oral candidiasis: a fungal infection commonly associated with immunosuppression. It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.

Question 32

What is the following clinical sign and what does it suggest?

Answer 32

Hyperpigmented macules: pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.

Question 33

List some abdominal causes of lymphadenopathy

Answer 33

The left supraclavicular lymph node (known as Virchow’s node) receives lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy (most commonly gastric cancer).

The right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera).

Question 34

What is the following clinical sign and what does it suggest?

Answer 34

Spider naevi: skin lesions that have a central red papule with fine red lines extending radially caused by increased levels of circulating oestrogen. Spider naevi are commonly associated with liver cirrhosis, but can also be a normal finding in pregnancy or in women taking the combined oral contraceptive pill. If more than 5 are present it is more likely to be associated with pathology such as liver cirrhosis.

Question 35

What is the following clinical sign and what does it suggest?

Answer 35

Gynaecomastia: enlargement of male breast tissue caused by increased levels of circulating oestrogen (e.g. liver cirrhosis). Other causes include medications such as digoxin and spironolactone.

Question 36

What may cause abdominal distension?

Answer 36

Abdominal distension: can be caused by a wide range of pathology including the six f’s (fat, fluid, flatus, faeces, fetus or fulminant mass).

Question 37

What is the following clinical sign and what does it suggest?

Answer 37

Caput medusae: engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).

Question 38

What is the following clinical sign and what does it suggest?

Answer 38

Striae (stretch marks): caused by tearing during the rapid growth or overstretching of skin (e.g. ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy).

Question 39

What is the following clinical sign and what does it suggest?

Answer 39

Cullen’s sign: bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign).

Question 40

What is the following clinical sign and what does it suggest?

Answer 40

Grey-Turner’s sign: bruising in the flanks associated with haemorrhagic pancreatitis (a late sign).

Question 41

What things should you comment on in regards to a stoma?

Answer 41

Location: this can provide clues as to the type of stoma (e.g. colostomies are typically located in the left iliac fossa, ileostomies and urostomies are typically located in the right iliac fossa).

Contents: can be stool (e.g. colostomy or ileostomy) or urine (e.g. urostomy).

Consistency of stool: note if it is liquid (ileostomy) or solid (colostomy).

Spout: colostomies are flush to the skin with no spout whereas ileostomies and urostomies have a spout.

Question 42

Define the following:

• Tenderness.
• Rebound tenderness
• Voluntary guarding
• Involuntary guarding/rigidity
• Rovsing’s sign
• Masses

Answer 42

Tenderness: note the abdominal region(s) involved and the severity of the pain.

Rebound tenderness: said to be present when the abdominal wall, having been compressed slowly, is released rapidly and results in sudden sharp abdominal pain. This is a non-specific, unreliable clinical sign that can, in some cases, be associated with peritonitis (e.g. appendicitis).

Voluntary guarding: contraction of the abdominal muscles in response to pain

Involuntary guarding/rigidity: involuntary tension in the abdominal muscles that occurs on palpation associated with peritonitis (e.g. appendicitis, diverticulitis).

Rovsing’s sign: palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa. This sign was historically said to be indicative of appendicitis, but it is not reliable and at best indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa.

Masses: large or superficial masses (e.g. hernias) may be noted on light palpation.

Question 43

If a mass is felt on palpation, what should you comment on?

Answer 43

If any masses are identified during deep palpation, assess the following characteristics:

Location: note which of the nine abdominal regions the mass located within.

Size and shape: assess the approximate size and shape of the mass.

Consistency: assess the consistency of the mass (e.g. smooth, soft, hard, irregular).

Mobility: assess if the mass appears to be attached to superficial or underlying structures.

Pulsatility: note if the mass feels pulsatile, suggestive of vascular aetiology (e.g. abdominal aortic aneurysm).

Question 44

What does a liver edge below the costal margin indicate?

Answer 44

Degree of extension below the costal margin: if greater than 2 cm this suggests hepatomegaly.

Question 45

What does a nodular liver edge suggest?

Answer 45

Consistency of the liver edge: a nodular consistency is suggestive of cirrhosis.

Question 46

What does hepatic tenderness suggest?

Answer 46

Tenderness: hepatic tenderness may suggest hepatitis or cholecystitis (as you may be palpating the gallbladder)

Question 47

What does a pulsatile liver edge indicate?

Answer 47

Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation.

Question 48

List 5 causes of hepatomegaly

Answer 48

Causes of hepatomegaly

There is a wide range of possible causes of hepatomegaly including but not limited to:

• Hepatitis (infective and non-infective)
• Hepatocellular carcinoma
• Hepatic metastases
• Wilson’s disease
• Haemochromatosis
• Leukaemia
• Myeloma
• Glandular fever
• Primary biliary cirrhosis
• Tricuspid regurgitation
• Haemolytic anaemia

Question 49

What may a distended gall bladder suggest?

Answer 49

In healthy individuals, the gallbladder is not usually palpable. If the gallbladder is palpable it suggests enlargement secondary to biliary flow obstruction (e.g. pancreatic malignancy, gallstones) and/or infection (e.g. cholecystitis).

If the gallbladder is enlarged, a well-defined round mass that moves with respiration may be noted. Tenderness suggests a diagnosis of cholecystitis whereas a distended painless gallbladder may indicate underlying pancreatic cancer (particularly if also associated with jaundice).

Question 50

What is murphys sign?

Answer 50

Murphy’s sign

1. Position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge.
2. Ask the patient to take a deep breath.

If the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis (known as “Murphy’s sign positive”).

Question 51

What may an enlarged spleen suggest?

Answer 51

In healthy individuals, you should not be able to palpate the spleen. A palpable spleen at the edge of the left costal margin would suggest splenomegaly (for the spleen to be palpable at this location it would need to be approximately three times its normal size).

Causes of splenomegaly

There is a wide range of possible causes of splenomegaly including but not limited to:

• Portal hypertension secondary to liver cirrhosis
• Haemolytic anaemia
• Congestive heart failure
• Splenic metastases
• Glandular fever

Question 52

What may enlarged kidneys suggest?

Answer 52

Causes of enlarged kidneys

Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.

A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.

Question 53

Your hand moves out whilst assessing aortic pulse, what are you concerned about?

Answer 53

In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.

If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).

Question 54

What may a distended bladder suggest?

Answer 54

Before performing bladder palpation, allow the patient the opportunity to go to the toilet. Warn the patient that palpation may be uncomfortable and bring about the sudden urge to pass urine.

A distended bladder can be palpated in the suprapubic area arising from behind the pubic symphysis (e.g. urinary obstruction/retention). In most healthy patients who are passing urine regularly, the bladder will not be palpable.

Question 55

What is shifting dullness?

Answer 55

Percussion can also be used to assess for the presence of ascites by identifying shifting dullness:

1. Percuss from the umbilical region to the patient’s left flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank.
2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the patient to roll onto their right side (towards you for stability).
3. Keep the patient on their right side for 30 seconds and then repeat percussion over the same area.
4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).

Question 56

What may tinkling bowel sounds suggest?

Answer 56

Tinkling bowel sounds: typically associated with bowel obstruction.

Question 57

What may absent bowel sounds suggest?

Answer 57

Absent bowel sounds: suggests ileus which is a disruption of the normal propulsive ability of the intestine due to a malfunction of peristalsis. Causes of ileus include electrolyte abnormalities and recent abdominal surgery. To be able to confidently state that a patient has ‘absent bowel sounds’ you need to auscultate for at least 3 minutes (this is unlikely to be the case in an OSCE given the time restraints).

Question 58

What are the causes of aortic and renal bruits?

Answer 58

Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.

Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis.

Question 59

What is the following clinical sign and what does it suggest?

Answer 59

Assess the patient’s lower legs for evidence of pitting oedema which may suggest hypoalbuminaemia (e.g. liver cirrhosis, protein-losing enteropathy).

Question 60

What further investigations would you request at the end of an abdominal examination?

Answer 60

Further assessments and investigations

Check hernial orifices (e.g. if there are signs of bowel obstruction). See our hernia examination guide for more details.

Perform a digital rectal examination (PR) (e.g. if there is suspicion of gastrointestinal bleeding).

Perform an examination of the external genitalia (e.g. to rule out testicular torsion as a cause of referred abdominal pain or an indirect inguinal hernia).