MRCS-B: Clinical Examination

1. Abdomen

Stem: Miss Baker is a 23-year-old lady with complain of abdominal pain for the last 24 hour. Please examine her abdomen.

  1. Introduction:
    —Wash your hands
    —Introduce yourself to the patient (Hi! I am Dr. X.)
    —Confirm the patient’s identity. (May I know your name, please? & What should I call you?)
    —Take Permission (May I examine you today please? or, I have been asked to examine you. Is that OK with you?)
    —Exposure (Ask the patient for exposure & help the patient for the same; limbs, chest & abdomen should be exposed).
    —Position of the pt. (The patient should be supine with their head supported by a pillow)
    —Ask the patient where is the pain.

  2. General inspection:
    —Look around the bed for oxygen, IV fluids etc.
    —Get a general impression of the pt. e.g. look in pain, holding abdomen, increased respiratory rate etc.

  3. General Examination:
    ~Start at the hands:
    —Inspect for stigmata of liver disease – unlikely to be found in this case, but they are:
    -Palmar erythema,
    -Dupuytren’s contracture,
    -Spider naevae
    —Palpate the pulse, for rate & rhythm

    —Request the patient to hold out the hands as if halting traffic, testing for a liver flap (again not relevant in such a young pt.)

    —Examination of the mouth:
    -Oral hygiene
    -Central cyanosis
    -the pigmentation seen in Peutz-Jeghers,
    -Aphthous ulcers seen in Crohn’s disease.

    —Examination of the eyes:
    -Icterus (jaundice),
    -Xanthelasma (unlikely in this young pt)

    —Feel in the left supraclavicular fossa for Virchow’s node.

  4. Abdominal Examination Proper:
    {Go to the abdomen for look, feel/touch, tap & hear i.e. inspect, palpate, percuss, auscultate (IPPA); tell the pt what you are going to do, e.g. I am going to touch & tap your abdomen/belly. Is that OK with you? Please stop me if anytime you feel pain.)

    Inspection: Look for obvious mass, distension, scars, stomas, hernias, and drains. Ask the patient to take a deep breath in, out and to cough, then to lift head off end of the bed. This increases the intra-abdominal pressure making hernias more obvious.

Check again for pain, and palpate in all 9 abdominal areas. You should kneel down so that you are at the patient’s level and look at their face for signs of discomfort. First light palpation, then deep palpation, feeling for masses.

As there is pain in the RIF, it is appropriate to test for Rovsing’s sign – palpation in the LIF causes more pain in the RIF.

Also look for Murphy’s sign – laying a hand on the right upper quadrant produces pain on inspiration, indicating an inflamed gall bladder

Now palpate for a liver, starting in the RIF and working up. It looks smoother if you then percuss for a liver.

Palpate for a spleen, again starting in the RIF, and palpate in the same way.

Ballot for kidneys bilaterally, pushing up with the posterior hand, a ballotable kidney is an abnormally large kidney

Place two open palms onto the abdomen either side of the aorta, above the umbilicus, and feel for an expansile pulsatile mass.

Percuss the tender area – a kinder way to test for rebound tenderness

Percuss for a large bladder and for ascites – testing for shifting dullness

Auscultate for bowel sounds

To finish my examination I would examine the external genitalia, perform a digital rectal examination, and examine the observation chart

Turn to the examiner, hands behind back and present your findings