To begin

Wash your hands, introduce yourself, gain the patient’s consent, ask if they have any pain. Adequately expose the patient (normally this is from nipples to knees). The patient should lie as flat as they comfortably can with their arms relaxed at their sides.

Stand at the end of the bed (with your hands behind your back!)

Comment on your general impression of patient (are they well? unwell, alert?)

Look for clues: eg. Jaundice (liver disease), pigmentation (haemachromatosis), cachexia (malignancy). Is there a stoma? IV lines? Feeding?

Hands

Look for clues: Clubbing (Inflammatory Bowel Disease, cirrhosis, GI lymphoma, malabsorption eg. Coeliac), Leuconychia (white nails associated with chronic liver disease), Kolionychia (spoon shaped nails associated with iron deficiency), Palmer Erythema (red palms associated with cirrhosis), Dupytren’s Contracture (contracture of palm associated with liver disease), Asterixis (also called liver flap, a coarse tremor seen in liver failure). Take the pulse (tachycardia may indicate GI haemorrhage/infection).

Arms

Look for Spider naevi (central arteriole from which smaller vessels radiate), bruising (clotting abnormalities in liver failure), wasting (malignancy), scratch marks (due to severe itching from jaundice).

Eyes

Examine sclera for jaundice (yellow) and conjunctivae for anaemia (white)

Kayser-Fleisher rings (copper deposition in Wilson’s disease).

Mouth

Does the breath smell? This could be associated with liver failure, fetor herpeticus, a sweet smell) or in DKA ketones can smell like nail polish remover. Look for Angular stomatitis (cracks at corners of mouth associated with vitamin B12, folate and iron deficiency. Look at the gums for gingivitis/ bleeding (associated with Scurvy). Look at the tongue for glossitis ( a smooth red tongue ) seen in vitamin B12 deficiency. Look for mouth ulcers (associated with Crohn’s and Coeliac disease).

Neck

Palpate the cervical and supraclavicular lymph nodes (associated with malignancy of GI tract or lung. Troisier’s sign is a large left supraclavicular node in presence of stomach cancer.

Chest

Look for Gynacomastica (breasts in men – associations include chronic liver disease and drugs) and Spider Naevi.

Abdomen

Inspect everywhere, including the flanks! Ask patient to cough (look for hernias). Look for: scars, distension, caput Medusae (prominent veins on the abdominal wall seen in severe portal hypertension), striae (stretch marks associated with Cushing’s disease, ascites, pregnancy, weight gain), bruising, masses, visible peristalsis (this can be normal in very thin people but suggests intestinal obstruction).

Then squat beside the patient and palpate in all 4 quadrants both superficially with light pressure and then deeply. Look at the patient’s face and see if they are in pain. Always palpate the painful area last.

Palpate for guarding (contraction of abdominal muscles in response to palpation may suggest peritonitis or a nervous patient!) and rigidity (constant involuntary contraction). Is there rebound tenderness (when the abdominal wall is compressed slowly and then released rapidly resulting in pain)? Are there any masses? Is there hepatomegaly (big liver) begin your palpation in the right iliac fossa. If felt describe the liver surface. Palpate for splenomegaly (big spleen) and for kidneys. Palpate for an abdominal aortic aneurysm.

Percuss liver (estimate the liver span), spleen, bladder, ascites. If the flanks are dull percuss for shifting dullness.

Auscultate for bowel sounds and renal bruits

Legs

Brusing. Oedema.

Then state “ to complete my examination I would like to …..”

• Examine the external gentialia
• Examine the hernial orifices
• Examine the inguinal lymph nodes
• Peform a PR examination
• Dipstick urine
• Record BP
• Record temperature