Abdominal Examination

Core Presentations

1. Kidney Transplant

2. Chronic kidney disease- dialysis

3. Polycystic Kidney Disease

4. Liver Transplant

5. Chronic Liver Disease

6. Hepatomegaly

7. Hepato-splenomegaly

8. Splenomegaly

9. Normal Examination

Abdominal Examination

6 minutes

Introduction + Inspection

WINDEC:

• Wash hands, introduce yourself

• Ask for name, ask in any pain

• Explain the examination and ask for consent

Exposure

• Lying 45 degrees- abdomen exposed, if male ask to take top off and move shorts onto hips; female- shorts onto hips and top to below the bra line (and chest inspection when do it, then re-cover up)

Inspection

End of the bed 

• Patient: jaundice, ascites, masses, caput medusa, tattoos, scars, nutritional status, bruising

• Medications/ devices around the bed- creon, oxygen

• Breathe to calm own nerves + steady self 

Chest, back, abdomen

• Inspection: spider naevi > 5; gynaecomastia (palpate)

• Important to look at the back for posterior nephrectomy scars (easy to miss)

Peripheral

Lower limbs

• Peripheral oedema

Hands

• Hands: duputyren's contracture, palmar erythema, jaundice

• Nails: finger clubbing, leukonychia, kolionychia,

• Tremor: fine/ coarse

• Flap (ideally 10s)

• Pulse: regular, rate

Arms

• Lines or fistulas (!)- recent access, buzz palpate, thrill

• Auxillary lymphadenopathy  [ :-( ] : end of exam with gloves

Neck

• JVP- hepatojuglar reflex is normal

• Cervical lymphadenopathy

Face

• Eye- conjunctival pallor, scleral jaundice

• Mouth- tongue: central cyanosis, mouth ulcers (Crohns)

Chest & Back

• Inspection- another chance

Abdomen

Adjust the patient height: the patient should be lying flat- not doing this could result in a fail

Inspection

• Scars- use finger to trace outline to highlight to examiner

• Jaundice, masses, bruising

Palpation

• Superficial for tenderness, (start in LIF as nil masses there)

• Deep for masses (two hands)

• Palpate liver edge- if able to feel liver: hepatomegaly, RIF to RUQ, push on inspiration

• Palpate spleen edge- splenomegaly if able to feel, RIF to LUQ, push inspiration

• Aortic aneurysm- normal to feel aorta (pulsatile mass, not expansile) in young skinny

• Ballot kidneys- loin- just above iliac posteriorly, normal to feel aorta in young skinny

• Bladder

Percussion

• Hepatomegaly- RIF to right shoulder, above (nipple line) and below; typically 5th intercostal space to lower costal margin

• Splenomegaly- RIF to LUQ

• Shifting dullness- percuss across abdomen, [roll onto their right side] and repeat percussion on raised left flank- ?fluid moved; can repeat splenomegaly palpation with patient on side 

• Bladder 

Auscultation

• Bowel sounds in RIF (ileocecal valve)

• Renal bruit- either side of umbilicus ?renal artery stenosis

• Auscultate liver ?hepatic bruit

Conclusion

• Thank patient, shake hands & assist to cover up, wash hands. 

• To the examiner: to complete my examination I would: aim to communicate you understand the station- e.g. in ESRD - BSL to look for diabetes, urine dip to look for protein and glucose and BP to look for a hypertensive cause or result of the ESRD; consider PR, examine hernia orifices and for inguinal lymphadenopathy. 

Core Signs

End of the bed-ogram

• Creon: pancreatic insufficiency / malabsorption ?IBD

• BMI= weight/ height squared

• Jaundice- acute or chronic liver disease, prehepatic/ hepatic/ post hepatic

• Bruising- trauma, coagulopathy + thrombocytopenia, blood thinners

• Rough age, gender, ethnicity

Peripheral

Lower limbs

• Peripheral oedema

  • Bilateral: failures hypoalbuminaemia: heart, liver, kidneys; malignancy, nutrition

  • Unilateral: DVT/ lymphatic obstruction

  • Ascertain height of pitting oedema

• Dermatitis herpetiformis- coeliac, lymphoma, thyroid disease: b/l itchy rash (can be peri-oral)

Hands

• Finger clubbing:

  • Liver cirrhosis, IBD, Coeliac

  • Cyanotic heart disease, pulmonary fibrosis, lung cancer, bronchiectasisis

• Duputren's contracture- idiopathic, chronic liver disease

• Palmar erythema- chronic liver disease, thyrotoxicosis, pregnancy

• Chronic liver disease: Duputyren's contracture, palmar erythema, leukonychia, kolionychia, jaundice

• Fine tremor: tacrolimus, alcohol

• Flap: hepatic encephalopathy, uraemic encephalopathy, C02 retention

• Pulse: 

  • Atrial Fibrillation

  • Tachycardia- dehydration, anxiety/ stress, bleeding

Arms

• Venous Lines- long hospital admission- antibiotics OM/ nutrition- TPN, 

• Fistulas- end stage renal disease, recent needle suggests ongoing haemodialysis & if renal transplant present if its functioning

Neck

• JVP- fluid overload- raised in failure: heart, liver, kidney; & malignancy

• Cervical lymphadenopathy- left supraclavicular lymph node (virchow's node) can suggest gastric cancer (Trosier's sign)

• Parotid swelling: alcoholic hepatitis, acute infection, Sjogren's, 

Face

• Conjunctival pallor- anaemia- chronic disease, maladsorption- B12, folate, alcohol, IBD, cirrhosis

• Jaundice- acute or chronic liver disease, prehepatic/ hepatic/ post hepatic

• Mouth: ulcers- Crohns, dentition

• Tongue- enlarged (cyclosporin), 'beefy'- B12 deficiency, candidiasis, atrophic glossitis- IDA

Chest

• Spider naevi > 5- liver cirrhosis, COCP, pregnancy, PBC, 

• Gynaecomastia: chronic liver/ renal disease, spironolactone, idiopathic, thyrotoxicosis

• Scars: posterior-lateral scars: nephrectomy

Abdomen

Inspection

• Scars

• Jaundice- acute or chronic liver decompensation, pre-hepatic/ hepatic/ post hepatic

• Masses- malignancy, organomegaly, renal transplant

Palpation + Percussion

Hepatomegaly

• Portal hypertension: chronic liver disease- alcohol, MASLD, viral HBV + HCV, haemochromatosis;

• Acute liver disease- acute hepatitis- alcohol, viral hep A, B, E (CMV/ EBV)

• Cor pulmonale

  • Hepatomegaly on percussion not on palpation- raised left hemidiaphragm, lobectomy

Hepatosplenomegaly

• Portal hypertension (chronic liver disease)

Splenomegaly

• Malignancy- Lymphoma

• Accumulation of faulty cells: CML, Hereditary Spherocytosis

• Reactive- infective: EBV, Malaria, inflammatory: Sarcoidosis

• Myeloproliferative: Myelofibrosis, Haemolytic Anaemia

Bilateral kidney masses

• Autosomal Dominant Polycystic Kidney Disease

• Differentials: bilateral RCC

• High BP, haematuria

Unilateral kidney palpation

• Unilateral nephrectomy- ?scar, ?renal transplant

  • Causes: RCC, severe infection/ stone, create space in ADPKD for transplant

Expansile, pulsatile abdominal mass

• Greater than 2 finger breadths concerning for AAA

  • Suggest- review any recent imaging of abdomen ?screening, history ?asymptomatic + BP, USS to assess ?dilated

Shifting dullness

• Ascites- decompensated liver disease, intrabdominal malignancy- SAAG, transudate/ exudate

Bladder- dull to percuss & palpable mass (unlikely in the exam): differentials

• Retention

• Bladder cancer mass

Auscultation

• Abdominal aorta

• Renal bruit

• Bowel sounds

Core COnditions 

Decompensated liver disease

• Signs: jaundice, ascites, bleeding- oesphageal/ rectal varices, bruising, encephalopathy

• Chronic

  • Causes: Alcohol, MASLD, viral HBV + HCV, haemochromatosis, paracetamol 

  • Signs: portal hypertension- caput medusa; chronic changes- palmar erythema, duputyren's contracture

• Acute

  • Causes: acute hepatitis- alcohol, viral hep A, B, E; drugs- paracetamol OD (rarely causes ascites)

End stage renal disease

• Fistula

• Central lines

• Causes - diabetes, 

• Abdominal scars

Renal Transplant

• Large scar in LIF and RIF

• Bilateral ballotable kidneys

• End stage renal disease (fistula/ lines)

• Commonest cause (4) of renal transplant: diabetes, hypertension, ADPKD, glomerulonephritis

Kidney Transplant

• Mass in LIF or RIF with scar. 

• Often the original kidney is left, worth checking for a scar to see if it has been removed. 

• Signs of end stage kidney disease- fistula: haemodialysis or peritoneal dialysis. 

• Questions of kidney disease ?polycystic ?diabetes, e.g.. 

Chronic kidney disease- dialysis

• Signs of end stage kidney disease- fistula: haemodialysis or peritoneal dialysis. 

• Cause of kidney disease ?polycystic ?diabetes, e.g.. 

Polycystic Kidney Disease

• Signs: bilateral ballotable kidneys +- hepatomegaly +- renal transplant/ ESRD

• Genetic: autosomal dominant

• Types: ADPKD1, ADPKD2

• Diagnosis: imaging + genetic testing

• Investigations: 

Liver Transplant

• Stigmata of chronic liver disease- dupuytren contracture, palmar erythema, finger clubbing

• Cause of liver decompensation- e.g. metabolic syndrome

• Scar

Chronic Liver Disease

• Dupuytren contracture, palmar erythema, finger clubbing

• Decompensation- jaundice, ascites, encephalopathy (flap), bleeding- oesphageal/ rectal varices, caput medusa (portal hypertension)

Hepatomegaly 

Aetiology

• Chronic liver disease: Alcoholic hepatitis, Fatty liver disease- MASLD; with portal hypertension it is common to not be able to detect the splenomegaly

• Liver Cancer

• Polycystic liver disease- may have polycystic kidney massess palpable

Hepatosplenomegaly 

Aetiology

• Chronic liver disease with portal hypertension- note it is unusual to be able to detect the splenomegaly

• Reactive (spleen is lymph node): 

Splenomegaly 

Aetiology

• Felty's syndrome, 

• Reactive (spleen is lymph node): EBV

Massive splenomegaly: myelofibrosis, CML, primary splenic lymphoma

Normal Examination

• Don't make up signs 

Presentation

Key points

• First present the signs. Then stop talking and listen to the examiners hints/ direction. 

• Signs can be grouped, e.g. into stigmata of chronic liver disease

• It is very easy to forget some of the signs at the start of the examination in e.g. the hands and the examiner can only mark you on the positive signs you state at the beginning of the presentation

If you've examined correctly, identified the correct signs and remember to state them, you've likely passed the station. 

Core Presentations

1. Kidney Transplant with RRT

I examined Ms Jones. There was a J shaped scar in the right illiac fossa with a palpable mass beneath. This would be consistent with a renal transplant. There were two abominal scars- one 3cm midline below the umbilicus and another 2cm scar laterally, which could be consistent with peritoneal dialysis. There was a fistula with a palpable thrill and no needling skin changes consistent with recent use. The patient is euvolaemic, therefore this suggests the renal transplant is functioning. In the absence of ballotable masses or evidence of needlestick signs from diabetes, the most common cause would be hypertensive nephropathy. 

2. Polycystic Kidney Disease

I examined Ms Jones. There was one ballotable mass in each of the left and right groins. They were irregular and I was able to get above. This would be consistent with polycystic kidney disease. There were no signs of renal replacement therapy and Joe was euvolaemic. 

3. Liver Transplant

I examined Ms Jones. There were stigmata of chronic liver disease- palmar erythema and duputyrens contracture and a large 15 cm transverse scar across the upper abdomen. This scar could be consistent with a liver transplant, although other hepatobiliary surgeries such as malignant liver resection or bilateral adrenalectomies would also be possibilities. In summary these signs would be consistent with chronic liver disease resulting in a liver transplant. There were no signs of hepatic decompensation on examination. Given the patients normal weight, the commonest cause of chronic liver disease in this patient would be alcohol related.

4. Chronic Liver Disease

I examined Ms Jones. There were stigmata of liver disease- palmar erythema, duputyrens contracture, gynaecomastia, ascites, jaundice and hepatosplenomegaly. The ascites and jaundice are consistent with liver decompensation and the duputyren's contracture and gynaecomastic suggest a chronic disease. Given Ms Jones' metabolic profile, the likely cause of her decompensated liver disease would be MASLD. 

5. Hepatomegaly

I've examined Ms Jones. My positive findings are hepatomegaly of 3cm below the sternal margin, non tender; and a midline umbilical scar 3cm which could be consistent with an umbilical hernia.

6. Hepato-splenomegaly

I've examined Ms Jones. My positive findings are hepatosplenomegaly. The hepatomegaly was 4cm below the sternal margin and tender. There was a mass in the left upper quandrant that I was unable to get above, consistent with splenogemaly 3cm below the sternal margin. The commonest cause of hepatosplenomegaly would be portal hypertension and given the patients BMI, alcohol would be the commonest cause. There was no signs of liver decompensation. 

7. Splenomegaly

I've examined Ms Jones. My positive findings are splenomegaly 5cm below the sternal margin. There was a mass in the LIF that I was unable to get above. In the abscence of other clinical signs my differential would be broad, but include haematological malignancy, infection and inflammatory. 

8. Normal Examination

I've examined Ms Jones. My examination was normal and I did not elicit any positive clinical signs. 

Discussion

My impression is that this is lowest impact part of the station and one where it is tempting to spend a large amount of time learning obscure knowledge for. These questions tend to be fair and follow the following structure: 

• Differentials

• Investigations

• Management

• Complications

Questions

Why could you percuss hepatomegaly and not palpate it? Raised left hemidiaphragm

References

1. https://britishlivertrust.org.uk/information-and-support/liver-conditions/cirrhosis/portal-hypertension/

2. AL Ghabra Y, Goldin J, Pandey S. Parotitis. [Updated 2025 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560735/

3. Burcovschii S, Aboeed A. Nail Clubbing. [Updated 2022 Sep 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539713/