Obviously, it is always important to do a general examination of the
patient. In particular, attention should be paid to signs of shock or dehy-
dration as manifested by peripheral shut-down, clamminess, pallor, tachy-
cardia and hypotension. One can often tell, just by looking at the patient,
whether he is unwell. The typical patient with peritonitis looks pale and
sweaty, with sunken eyes and a weak thready pulse, shallow breaths and
little movement — as first described by Hippocrates thousands of years ago.
Introduce yourself to the patient, ask if he minds your examining him
and if he has any pain. Lay him flat (one pillow) and adequately undress
him (ideally from nipples to knees, but in the exam you should try to pre-
serve the patient’ s dignity). On inspection of the abdomen (from the foot
of the bed) observe for any obvious scars or masses, distension and the
movement with respiration. You may find it easier in an exam situation to
comment on your observations as you go along (unless you are confi-
dent you can present it all at the end). It is sometimes difficult to differ-
entiate fat from distension (which can be due to flatus or fluid or foetus
or faeces)
Next, hold the hand and look for any nail changes (e.g. clubbing), liver palms, etc.,
feel the pulse, look into the mouth for furring of the tongue and for dry mucous
membranes, look into the eyes for jaundice or anaemia (pale conjunctiva) and
swiftly feel the neck for any lymph nodes.
On palpation of the abdomen (make sure the hands are warm) kneel
down to the patient’ s right, so that you are roughly level with him. The
abdomen can be divided into theoretical regions.
Starting at the furthest point from where he tells you the pain is, gently feel in each
of these regions. This gives you a quick idea of any obvious masses or
tender areas and whether the abdomen is soft. You should begin to think
of what anatomical structures are under this area. Always look up at the
patient’ s face (for grimacing). Next you can palpate a little deeper to build
up on the findings of gentle palpation. Note if there is any guarding, rigidity
or rebound. Rebound tenderness (most painful when the examining hand
is removed) is not a good test, as it often causes the patient unnecessary
pain and can give equivocal results. Tenderness on percussion is a more
accurate and kinder way of assessing the same thing.
Examine the liver and spleen (starting in the right iliac fossa for both,with the patient inspiring each time you press in). In right upper quadrant abdominal pain, Murphy’ s test for cholecystitis is relevant, and if any masses or enlarged organs are palpated then the precise features need to be delineated. After palpation, percussion should be used before auscultation. Bowel sounds should be classified as being present (i.e. normal), absent (must listen for 3min) or obstructive (high-pitched and tinkling).
patient. In particular, attention should be paid to signs of shock or dehy-
dration as manifested by peripheral shut-down, clamminess, pallor, tachy-
cardia and hypotension. One can often tell, just by looking at the patient,
whether he is unwell. The typical patient with peritonitis looks pale and
sweaty, with sunken eyes and a weak thready pulse, shallow breaths and
little movement — as first described by Hippocrates thousands of years ago.
Introduce yourself to the patient, ask if he minds your examining him
and if he has any pain. Lay him flat (one pillow) and adequately undress
him (ideally from nipples to knees, but in the exam you should try to pre-
serve the patient’ s dignity). On inspection of the abdomen (from the foot
of the bed) observe for any obvious scars or masses, distension and the
movement with respiration. You may find it easier in an exam situation to
comment on your observations as you go along (unless you are confi-
dent you can present it all at the end). It is sometimes difficult to differ-
entiate fat from distension (which can be due to flatus or fluid or foetus
or faeces)
Next, hold the hand and look for any nail changes (e.g. clubbing), liver palms, etc.,
feel the pulse, look into the mouth for furring of the tongue and for dry mucous
membranes, look into the eyes for jaundice or anaemia (pale conjunctiva) and
swiftly feel the neck for any lymph nodes.
On palpation of the abdomen (make sure the hands are warm) kneel
down to the patient’ s right, so that you are roughly level with him. The
abdomen can be divided into theoretical regions.
Starting at the furthest point from where he tells you the pain is, gently feel in each
of these regions. This gives you a quick idea of any obvious masses or
tender areas and whether the abdomen is soft. You should begin to think
of what anatomical structures are under this area. Always look up at the
patient’ s face (for grimacing). Next you can palpate a little deeper to build
up on the findings of gentle palpation. Note if there is any guarding, rigidity
or rebound. Rebound tenderness (most painful when the examining hand
is removed) is not a good test, as it often causes the patient unnecessary
pain and can give equivocal results. Tenderness on percussion is a more
accurate and kinder way of assessing the same thing.
Examine the liver and spleen (starting in the right iliac fossa for both,with the patient inspiring each time you press in). In right upper quadrant abdominal pain, Murphy’ s test for cholecystitis is relevant, and if any masses or enlarged organs are palpated then the precise features need to be delineated. After palpation, percussion should be used before auscultation. Bowel sounds should be classified as being present (i.e. normal), absent (must listen for 3min) or obstructive (high-pitched and tinkling).
Always finish your examination by palpating for an abdominal aortic aneurysm and check the
hernial orificesand scrotum. A rectal examination is mandatory (although in an exam you usually
just state that you would like to do it). The breast is really part of the abdominal examination,
since if you were shown a case of ascites in the exam and you did not comment on the mastectomy
scar, you would not receive any bonus points!
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