Why Abdominal Examination Is a Core OSCE Station
The abdominal examination appears in virtually every OSCE circuit. It tests systematic technique, knowledge of anatomical landmarks, ability to elicit and interpret signs, and the skill of presenting findings clearly. The most common failures are: forgetting to ask about pain before palpating, skipping percussion, and presenting findings in a disorganised order.
This guide covers the complete examination with the clinical reasoning behind every step.
💡 Tip
Before you start: Always ask "Do you have any pain or tenderness in your abdomen at the moment?" before touching the patient. Palpating an already-painful abdomen without warning is both poor technique and a direct mark loss.
The Sequence
End of bed → Hands → Face → Neck → Chest → Abdomen (inspection → light palpation → deep palpation → organ palpation → percussion → auscultation) → Groins → Legs
1. End of Bed — General Inspection
Before approaching:
- Does the patient look well or unwell, jaundiced, or cachectic?
- Any distension visible from the end of the bed?
- Scars visible on the abdomen?
- Any stomas — ileostomy (right iliac fossa, liquid output), colostomy (left iliac fossa, formed stool), urostomy?
- IV lines, NG tube, urinary catheter — assess urine colour (dark = dehydration or haematuria or bilirubinuria)?
2. Hands
| Sign | Significance |
|---|---|
| Leuconychia (white nails) | Hypoalbuminaemia — liver disease, malnutrition |
| Koilonychia (spoon nails) | Iron deficiency anaemia |
| Clubbing | Inflammatory bowel disease, cirrhosis, coeliac |
| Palmar erythema | Chronic liver disease (CLD) |
| Dupuytren's contracture | Alcoholic liver disease |
| Asterixis (liver flap) | Hepatic encephalopathy — ask patient to hold hands outstretched, wrists extended for 15 seconds |
| Leukonychia | Hypoalbuminaemia |
Assess asterixis actively — it is frequently missed because students forget to test for it.
💎 Clinical Pearl
Dupuytren's contracture is a fibrosis of the palmar fascia causing fixed flexion of the ring and little fingers. It is associated with alcoholic liver disease but also occurs idiopathically, in manual workers, and in epilepsy. Don't over-interpret it in isolation — mention it and note the association.
3. Face and Neck
| Sign | Where | Significance |
|---|---|---|
| Jaundice | Sclera (best seen in natural light) | Bilirubin >35 µmol/L — pre-hepatic, hepatic, post-hepatic |
| Anaemia | Conjunctival pallor | GI blood loss, anaemia of chronic disease |
| Xanthelasma | Periorbital | Hyperlipidaemia — primary biliary cholangitis |
| Kayser-Fleischer rings | Corneal rim (requires slit lamp) | Wilson's disease |
| Angular stomatitis | Corners of mouth | Iron deficiency, B12/folate deficiency |
| Glossitis | Tongue — smooth, red | Iron, B12, or folate deficiency |
| Mouth ulcers | Buccal mucosa | Crohn's disease |
| Parotid enlargement | In front of the ear | Alcoholic liver disease |
| Virchow's node | Left supraclavicular fossa | Gastric cancer (Troisier's sign) — always palpate |
⚠️ Red Flag
Always palpate Virchow's node (left supraclavicular fossa). A hard, non-tender, fixed lymph node here is Troisier's sign — pathognomonic of intra-abdominal malignancy (usually gastric cancer). It is almost always asked about by examiners.
4. Chest
Briefly check for:
- Spider naevi — >5 on chest/upper body = CLD. Each is a central arteriole with radiating vessels that blanch on pressure and refill from the centre outward
- Gynaecomastia — excess oestrogen in CLD
- Loss of axillary hair — hypoestrogenism in CLD (also check pubic hair)
5. Abdomen — Inspection
Expose from nipples to knees (maintain dignity). Look for:
- Scars — identify and describe position (midline laparotomy, Kocher's/right subcostal for cholecystectomy, McBurney's for appendicectomy, Pfannenstiel for pelvic surgery)
- Distension — is it generalised or localised? (The 5 Fs: Fat, Fluid, Flatus, Faeces, Fetus/Foetal mass)
- Caput medusae — dilated veins radiating from the umbilicus, portosystemic collaterals in portal hypertension
- Visible peristalsis — suggests bowel obstruction
- Hernias — ask patient to cough and observe at umbilicus, groins, and any scar sites
🧠 Mnemonic
The 5 Fs of abdominal distension:
Fat, Fluid (ascites), Flatus, Faeces, Fetus (or large fibroid/mass)
In clinical practice, add a sixth: Full bladder (chronic urinary retention — surprisingly common).
6. Palpation
Always watch the patient's face for pain throughout palpation — not just your hands.
Light Palpation (all 9 regions)
Work systematically through all 9 regions (right hypochondrium → epigastrium → left hypochondrium → right flank → umbilical → left flank → right iliac fossa → suprapubic → left iliac fossa). Start away from any stated pain.
Feel for:
- Tenderness — ask "does this hurt?"
- Guarding — involuntary muscle contraction = peritoneal irritation
- Rigidity — board-like = generalised peritonitis
Deep Palpation
Repeat with firmer pressure to detect deeper masses. Characterise any mass:
- Site, size, shape
- Surface (smooth vs nodular)
- Consistency (soft, firm, hard)
- Tenderness
- Pulsatile? (Abdominal aortic aneurysm — expansile pulsation, not just transmitted)
- Moves with respiration?
Liver
Place your hand in the right iliac fossa, fingers pointing toward the right hypochondrium. Ask the patient to breathe in deeply — feel for the liver edge descending.
Normal liver: not palpable below the costal margin (or <2cm in thin individuals).
If palpable, describe:
- How many centimetres below the costal margin?
- Smooth or nodular edge?
- Tender or non-tender?
- Pulsatile? (Tricuspid regurgitation → pulsatile liver)
| Finding | Consider |
|---|---|
| Smooth, tender hepatomegaly | Hepatitis, right heart failure, Budd-Chiari |
| Smooth, non-tender | Fatty liver, haematological malignancy |
| Hard, irregular, nodular | Metastases, hepatocellular carcinoma, cirrhosis |
| Pulsatile | Tricuspid regurgitation |
Spleen
Start in the right iliac fossa (the spleen can be massively enlarged). Move toward the left hypochondrium with each breath. A palpable spleen is at least 2–3× its normal size.
💎 Clinical Pearl
The spleen vs kidney: A palpable spleen moves diagonally toward the RIF on inspiration, has a notch on its medial border, is dull to percussion, and you cannot get above it. A kidney moves vertically on inspiration, is ballotable (can be pushed forward from behind), and is resonant anteriorly (bowel overlies it). These distinguishing features are regularly asked about by examiners.
Kidneys
Bimanual palpation — one hand behind the loin, one hand anteriorly. Ballot the kidney upward and feel it descend on inspiration.
Aorta
Palpate in the midline, above the umbilicus. An expansile pulsation (fingers pushed apart) suggests an aortic aneurysm. A transmitted pulsation (fingers pushed forward together) is normal in thin patients.
7. Percussion
Percuss the liver span (upper border: start in the right mid-clavicular line from the lung, percuss downward until dull; lower border: percuss upward from the RIF). Normal liver span: 6–12 cm.
Percuss the spleen area (left lower lateral chest) — splenic dullness.
Ascites
Shifting dullness — the most important sign:
- 1Percuss from the umbilicus laterally until you find dullness (at the flanks)
- 2Keep your finger there and ask the patient to roll toward you
- 3Wait 10 seconds — the fluid settles
- 4Percuss again — dullness should shift to resonance (fluid has moved away)
A positive shifting dullness = ascites until proven otherwise.
Fluid thrill (for tense ascites):
- Place patient's hand on midline abdomen (to dampen fat transmission)
- Flick one flank and feel for the impulse on the other side
- Only positive in moderate-to-large ascites
💡 Tip
Shifting dullness is more sensitive than fluid thrill. Always test for shifting dullness first. Only proceed to fluid thrill if you suspect significant ascites and want to confirm. A negative fluid thrill does not exclude ascites.
8. Auscultation
Listen in the right iliac fossa:
- Normal bowel sounds — low-pitched gurgles, present intermittently
- Absent (after 2 minutes of listening) — ileus, peritonitis
- Increased/tinkling — bowel obstruction (high-pitched, frequent, "rushing")
Listen for bruits:
- Over the aorta (midline, above umbilicus)
- Renal arteries (paraumbilical, toward the flanks)
- Hepatic artery (right upper quadrant) — hepatoma, AVM
9. Complete the Examination
- Groins: inguinal lymphadenopathy, hernias (direct — medial to inferior epigastric; indirect — lateral, follows inguinal canal)
- External genitalia: mention you would examine if clinically indicated
- Digital rectal examination: mention you would perform if indicated (rectal mass, malaena, PR bleeding)
- Legs: peripheral oedema (pitting = hypoalbuminaemia, right heart failure)
How to Present Your Findings
"On examination, the patient appeared [well/cachectic/jaundiced]. Peripherally, I found [signs]. In the abdomen, inspection revealed [scars/distension/other]. On palpation, there was [tenderness / no tenderness], [organomegaly / no organomegaly]. The liver was [not palpable / palpable X cm below the costal margin, smooth/nodular, tender/non-tender]. The spleen was [not palpable / palpable, with a notch]. Percussion demonstrated [no shifting dullness / positive shifting dullness suggesting ascites]. Bowel sounds were [normal / absent / increased]. In summary, these findings are consistent with [diagnosis], and I would like to confirm with [investigations]."
Common Examiner Follow-Up Questions
"You've found a smooth, tender hepatomegaly — what are your differentials?"
"In the acute setting, I would consider viral hepatitis, alcoholic hepatitis, and right heart failure causing hepatic congestion. Other causes include Budd-Chiari syndrome and drug-induced liver injury. I would correlate with LFTs, hepatitis serology, and an echocardiogram if cardiac failure is suspected."
"The patient has shifting dullness — what would you do next?"
"I would confirm ascites with an ultrasound, which is more sensitive than clinical signs. I would then perform a diagnostic ascitic tap to send fluid for protein (to classify as transudate or exudate using Light's criteria), cytology, MC&S, and LDH. I would also request LFTs, albumin, clotting, and renal function."
"What are the causes of massive splenomegaly (crossing the midline)?"
"The classic causes of massive splenomegaly are: chronic myeloid leukaemia, myelofibrosis, malaria (in endemic areas), visceral leishmaniasis (kala-azar), and Gaucher's disease. In the UK, CML and myelofibrosis are the most important to mention."