Performing a systematic abdominal examination is a core skill for medical students and healthcare professionals.
This guide follows the standard OSCE (Objective Structured Clinical Examination) format, covering the “WIPER” introduction, peripheral signs of gastrointestinal disease, and the physical exam of the abdomen.
Before beginning the physical assessment, follow the WIPER acronym to ensure patient safety and professional standards:
W – Wash: Clean your hands using the World Health Organization (WHO) technique.
I – Introduce: State your name and role clearly to the patient.
P – Permission & Pain: Explain the procedure, obtain formal consent, and ask the patient if they are currently experiencing any pain.
E – Exposure: Ideally, expose the patient from the xiphisternum to the pubis. Maintain patient dignity by offering a clinical sheet and ensuring a private environment.
R – (Re)position: The patient should lie flat with one pillow and arms by their sides to relax the abdominal muscles.
Clinical signs of gastrointestinal and hepatic disease are often found outside the abdomen.
End of the Bed Inspection
Observe for “red flag” clinical signs:
Jaundice: Yellowing of the skin or sclera (suggesting liver failure or haemolysis).
Cachexia: Sign of malignancy or malabsorption.
Medical Equipment: Look for stoma bags, abdominal drains, or sick bowls.
Hydration Status: Check for “Nil by Mouth” signs or nutritional supplements.
Hands & Arms
Nails: Look for Leuconychia (hypoalbuminaemia), Koilonychia (iron deficiency), and Clubbing (IBD, cirrhosis, or coeliac disease).
Palms: Check for Palmar Erythema (liver disease/pregnancy) and Dupuytren’s Contracture.
Asterixis (Liver Flap): Ask the patient to ‘stop traffic’ with their hands. A coarse flapping tremor indicates hepatic encephalopathy or CO2 retention.
Face & Neck
Eyes: Inspect for Scleral Icterus (jaundice), Conjunctival Pallor (anaemia), and Kayser-Fleischer rings (Wilson’s disease).
Mouth: Look for Angular Cheilitis (iron/B12 deficiency), Glossitis (beefy red tongue), and Aphthous Ulcers (Crohn’s disease).
Neck: Observe the Jugular Venous Pressure (JVP); an elevated JVP with ascites may suggest right-sided heart failure.
Get down to eye level with the abdomen to look for:
Distension: Remember the 6 F’s: Fat, Fluid (ascites), Flatus, Faeces, Foetus, or Functional (obstruction).
Scars: Look for surgical scars (e.g. McBurney’s point for appendectomy or midline laparotomy).
Caput Medusae: Engorged veins around the umbilicus (portal hypertension).
Striae: Purple stretch marks (Cushing’s syndrome).
Always ask about pain before touching the abdomen and start palpation furthest away from the site of pain.
Light Palpation
Systematically palpate the nine abdominal regions. Assess for:
Tenderness: Localised pain.
Guarding: Involuntary tension of abdominal muscles (sign of peritonitis).
Deep Palpation
Press deeper to identify masses or organomegaly.
Palpating the Organs
Liver: Start in the Right Iliac Fossa (RIF). Move upwards toward the right costal margin as the patient inhales.
Spleen: Start in the RIF and move diagonally toward the Left Hypochondrium. A palpable spleen is usually at least 2x enlarged.
Kidneys: Use a “balloting” technique. Place one hand behind the flank and the other on the anterior abdominal wall.
Percussion
Liver & Spleen: Percuss to map out the borders of organomegaly.
Shifting Dullness (Ascites): Percuss from the umbilicus to the flank. If the sound changes from resonant to dull, have the patient roll toward you. If the dullness shifts back to resonance, ascites is confirmed.
Auscultation
Bowel Sounds: Listen for at least 30 seconds (5 seconds in an exam). “Tinkling” sounds suggest obstruction; absent sounds suggest ileus.
Bruits: Listen for Aortic bruits (above umbilicus) and Renal bruits (lateral to the midline) to screen for atherosclerosis or aneurysms.
To finish an OSCE abdominal exam, state you would also perform:
Hernial Orifice Examination: (Ask the patient to cough).
Digital Rectal Examination (PR): To check for melaena or prostate issues.
External Genitalia Exam.
Urinalysis: Check for glucose, protein, or blood.
For a visual guide, watch these expert demonstrations by Dr. James Gill:
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