Abdominal Examination OSCE: Step by Step

The abdominal examination rewards a calm, systematic routine: inspect, palpate, percuss, auscultate, then a focused set of completion steps. Examiners want to see you move smoothly from the hands to the abdomen, palpate the organs correctly while watching the patient's face, and pull your findings into a sensible conclusion. This guide gives you a reliable sequence to rehearse.

This is a revision draft; always check technique against your local mark scheme and a clinical supervisor.

Key points

• Follow inspect, palpate, percuss, auscultate, and always watch the patient's face during palpation.
• Position the patient lying flat with one pillow, exposed appropriately while preserving dignity.
• Palpate the liver and spleen from the right iliac fossa, and ballot the kidneys bimanually.
• Use percussion for organ borders and shifting dullness (ascites), and auscultate for bowel sounds and bruits.
• Offer to complete with hernial orifices, external genitalia, a rectal examination, observations and a urine dip.

Before you start

Wash your hands, introduce yourself with name and role, confirm the patient's identity, explain the examination and gain consent. Ask about pain before you touch the abdomen. Position the patient lying flat with a single pillow, with arms by their sides to relax the abdominal wall. Expose the abdomen appropriately while maintaining the patient's dignity.

General inspection

Look from the end of the bed. Is the patient comfortable or in pain? Note obvious clues: jaundice, cachexia, abdominal distension, or an obvious mass. Scan around the bed for stoma bags, surgical drains, a urinary catheter, feeding tubes, or medication.

Hands and arms

Inspect the hands for signs of chronic disease:

• Clubbing (associated with inflammatory bowel disease, cirrhosis and coeliac disease).
• Leuconychia (hypoalbuminaemia) and koilonychia (iron-deficiency anaemia).
• Palmar erythema and Dupuytren's contracture (associated with chronic liver disease).
• Asterixis (a flapping tremor of hepatic encephalopathy): ask the patient to hold their arms out with wrists cocked back.

Look at the arms for bruising and scratch marks (excoriations).

Face and neck

Inspect the eyes for scleral jaundice and conjunctival pallor. Look in the mouth for angular stomatitis, glossitis, aphthous ulcers, and the sweet smell of fetor hepaticus. In the neck, palpate for lymphadenopathy, specifically the left supraclavicular node (Virchow's node); an enlarged node here is called Troisier's sign and can indicate gastric malignancy.

Chest and inspection of the abdomen

On the chest, look for spider naevi and gynaecomastia (signs associated with chronic liver disease). Then inspect the abdomen closely for scars (previous surgery), distension, striae, caput medusae (distended periumbilical veins), visible peristalsis and any obvious masses or pulsation. Ask the patient to cough and look for a hernia or localised pain.

Palpation

Kneel to the patient's level. Palpate all nine regions, first lightly, then deeply, always watching the patient's face for discomfort and asking about tenderness. Note any masses, guarding or rigidity.

Then examine the organs:

• Liver: start in the right iliac fossa and move upward toward the right costal margin, asking the patient to breathe in so the liver edge meets your hand. Note any hepatomegaly, its size, edge and tenderness.
• Spleen: start in the right iliac fossa and palpate toward the left costal margin; the spleen enlarges toward the right iliac fossa, has a notch, and you cannot get above it.
• Kidneys: ballot each kidney bimanually, with one hand behind the flank and one on the abdomen.
• Aorta: palpate above the umbilicus for an expansile (not just pulsatile) mass, which raises concern about an abdominal aortic aneurysm.

Percussion

Percuss to define organ borders and to detect fluid:

• Liver and spleen: percuss their borders to confirm enlargement.
• Ascites: test for shifting dullness. Percuss from the midline out to the flank; if you reach dullness, keep your finger there, roll the patient toward you, pause, and percuss again. If the dullness has shifted to resonant, this suggests free fluid.
• Percuss over the bladder if it appears distended.

Auscultation

Listen for bowel sounds (present and normal, tinkling in obstruction, or absent in ileus). Listen for bruits over the aorta and renal arteries.

Completing the examination

State that to complete the examination you would examine the hernial orifices and external genitalia, perform a digital rectal examination, check the observations, and test the urine with a dipstick. Thank the patient and offer to help them dress.

Recognising the classic patterns

Pattern recognition turns signs into a diagnosis:

• Chronic liver disease: jaundice, palmar erythema, spider naevi, gynaecomastia, and possibly ascites and asterixis.
• Hepatomegaly: a liver edge palpable below the costal margin; causes include heart failure, malignancy and hepatitis.
• Splenomegaly: a mass in the left upper quadrant that you cannot get above, with a notch, moving with respiration.
• Ascites: distension with shifting dullness.
• Ballotable flank mass: consider a renal cause such as polycystic kidneys.

Presenting your findings

Be concise and structured: "On examination this comfortable gentleman had several stigmata of chronic liver disease, including palmar erythema and spider naevi. The abdomen was distended, non-tender, with shifting dullness suggesting ascites, and I could palpate a firm liver edge two centimetres below the costal margin. My findings are consistent with chronic liver disease. To complete I would examine the hernial orifices and external genitalia, perform a rectal examination, check the observations and dip the urine."

Make the sequence automatic

The abdominal station rewards a smooth, well-rehearsed routine. Practise the inspect, palpate, percuss, auscultate sequence out loud on a partner, especially the correct starting point in the right iliac fossa for the liver and spleen, until it comes without thinking.

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