Okay. So, we’ll start off by washing my
hands. Hello. My name is Sasha, one of the
doctors. Can I just check your name, please?
What’s your date of birth?
Great! I’ve got the right person. I was
just wondering if there’s any chance I could
do an examination of you, Tommy? Would that
be all right? This could involve you lying
flat. I’m going to have a look and then
I’m going to have a look at your hands and
your face, then I would have a feel of your
tummy if that’s all right? Can I get you
to lie flat for me, please? So ideally, I
don’t expose the patient. I’d say nipple
to knees, but as long as you got
So I’m just going to start by having a look
from the end of the bed. I’m kind of looking
around the bed for any signs of sick bowls
or any lines or tubes or anything else like
that. I can’t see anything obvious. Also,
just in the end of that examination of the
abdomen, I can’t see any obvious scars or
any hernias. Can I get you to have, if you
lift your head up so that you’re looking
towards your feet? That would make any hernias
a little bit more obvious. That’s fine.
You can relax for me.
So I’m going to move on to inspection of the
hands. Can I borrow both of your hands first?
So I’m just feeling the temperature, a little
bit cold. I’m checking capillary refill.
That’s fine. I’m looking for any nail
signs. So there’s no signs have clubbing
or oncholysis. Can I feel your pulses there?
That’s fine. So pulse is irregular and symmetrical.
I’m just going to have a look at your hands
as well. There is no palmar erythema and I’m
just going to feel across your palms, and
there are no contractures or anything else
like that. That’s fine. As I move up the
arm, I’m just having a look for any signs,
excoriation, if there are any skin lesions,
if there’s any trap marks, all of those
things could tie with liver disease.
Now, I’m coming up to your face. Can I get you
just to take your specs off for me? That’s
great. Would you be able to look up? And I’m
just going to draw your low eyelids down.
That’s fine if you look down for me. That’s
fine. You can put your specs back on again.
Wonderful! Can you open your mouth for me?
Stick your tongue out. That’s fine. So I
couldn’t see any signs in the eyes such
as anaemia, and I’m looking in the mouth
as well for any signs of aphthous ulcers or
a big tongue which might indicate a deficiency
of some sort. Do you have any pain in your
neck at all?
No. That’s fine. So I’m just going
just specifically for a node called Virchow’s
node which is associated with gastric malignancies.
Ideally I’d want to do full lymph node exam.
Okay. So I’m going to move on to have a
look at your tummy if that’s all right next?
So, on inspection, I’m looking for things
like scars. Is there any distension? Is there
any scratch marks? Is there any bruising?
Bruising around the umbilicus is called Cullen’s
sign, excellent. And any bruising around the
flanks, so you’d have a look at both sides.
Grey-Turner’s sign. Absolutely. So, Grey-Turner’s
with the retroperitoneal bleeding. So you
may think of it as a triple A. It has something
to do with the kidneys. Another thing to look
at is potential scars that go into the flanks
which might indicate --
Yeah. Absolutely, absolutely. I can’t see
anything obvious when I’ve examined you,
Tommy. So, would it be all right for me to
have a very quick feel of your tummy?
Yeah. Okay. It’s an important thing
to get down
to the patient’s level, and I’m keeping
my eyes focused on the patient. Is there any
sore at the moment?
What would you do if there was?
Start away from the area.
Yeah, start away from them. So, I was trying
to think of the light touch as you’re sort
of feeling out for any areas that might be
so -- okay. So I’m just going to start up
here. Just tell me if anything is feeling
sore. So I’m just systematically palpating
all nine quadrants and having a look at the
patient’s face for any signs the discomfort.
That’s all okay, sir?
Would it be alright for me to have a bit of
a deeper feel, Tommy? This time, the deeper
feel is more to feel for masses, pulsations.
Is there anything else obvious that I can
listen such as a deep pain when I’m palpating?
Again, I’d palpate deeply at all nine quadrants.
Things that you need to look for when you’re
palpating is the pain when you’re pushing
in, is it worst when you’re letting go?
That gives you an idea of whether or not there’s
any rebound tenderness. In terms of palpation,
I’m going to move on to just have a quick
feel of your kidneys if that’s okay? So
you just lay back. I’m just going to slip
my hand just behind your back. You relax for
me. I’m just going to press back and forth.
Is that feeling sore at all?
Okay. So you’re feeling for the size of the kidney.
That’s fine. And if it’s enlarged,
you might feel a renal mass, but you’re
also trying to feel if there’s any renal
angle tenderness. Next thing I want to do
is feel out for the liver. How do we do that?
Ask them to breath in and as they breath in,
you’d put your fingers through and it will
tap against them. Perfect! So I’m just going
to let the patient
know. I’m just going to see if I can feel
the side of your kidney, and I’m going to
start here, just above your hip, okay. What
I’d like you to do is take some deep breath
in and out. Breathe in, good, and breathe out.
Again, breathe in and out. Essentially, what
you’re doing is pushing in as the
patient breath in, and you’re trying to
catch that liver edge as it goes past. Okay.
You do the same for this spleen, where would
you start? Same place, yeah. Remember, if you
can feel any enlarged spleen,
it’s an enlarged spleen. It has to be about
three times the size which we’d be able
to palpate it. So again, you start from here.
You’re getting the patient to take breathe
in and out and go all the way across. If it
was a woman and she was potentially gravid,
you may also feel for a uterus as well, and
you can also palpate for the body. Okay.
But I won’t do that because you might want to
rush in the bathroom. What would you do after palpation?
Yeah, absolutely. I’m going to just have
a quick tap on you, Tommy, if that’s alright?
So again, I’m looking at his face
and I’m going to systematically, across
all nine quadrants. What is this useful for?
Yeah, ascites. So it’s checking to see if
there’s any fluid. What would you hear if
it was fluid?
Absolutely. So it’s quite an important sign
that you need to elicit as well. So, what
would you do in that case if you just saw
any abdominal distension that you wanted to
see if there was any fluid there? You’d
start from the centre and percuss out.
And then if you got to the point where your resonant
percussion note became a dull percussion note,
keep your finger on there and you’d ask
the patient to roll over to the side.
So, can I get you to roll over to the side? Please
don’t fall off the couch. Great! Keeping
your finger in the same place and you’d
say to them I’m going to keep you like this
for about 30 seconds. If I can demonstrate
that this dull percussion note has gone to
a resonant percussion note, then I’ve demonstrated
That’s fine. Can I get you to lay back?
We can also percuss out the borders of the
liver and the spleen as well. I’m going
to go onto auscultation. So just explain to
the patient what you’re doing. I’m going
to have a quick listen into your tummy as
well just to check your bowels. So, I’d
have to listen in. You can potentially have
to listen for up to three minutes to hear
bowel sounds and you just comment on whether
or not they’re present on what they sound
like. What’s the normal bowel sound?
Gurgling. Absolutely. So it’s just
bowel sound. If you’re hearing more than
that, what might that indicate?
Obstruction? Yeah, potentially. So they
might have some
sort of an ileus. And absent bowel sounds
again, that’s another sign. Absolutely, fine.
Okay. What I’d like to do now is I’ll cover
the patient over. Thank you very much
for letting me examine you. I’m going to
the examiner and I’d present my findings
so I’d say, on general inspection, there
was nothing to find. On the examination of
the abdomen, there were no signs of scarring
or distention. There was no tenderness when
I palpated both on light and deep palpations.
There was a normal percussion with no fluid
demonstrated and an auscultation bowel sounds
are present and normal. To complete my examination,
what sort of thing would you want to do?
Yeah. So when you’re talking about what
you do after the exam, try and talk about
examinations first and then investigation.
So yeah, urine dip is good. Say that again?
But not first. Hernias? Hernia. So we said hernias,
PR, external genitalia.
Yeah. You could look at the calves
for erythema nodosum
and stuff like that.
That’s a rare sort of thing.
The other thing I mention is doing an exam
of the lymph nodes as well because the liver
and spleen, big lymph nodes. Okay. Then you
go and say what investigations you do.
Yeah. FBC, U&E, abdominal X-ray, if it’s
abdominal ultrasound, have a look at the values
for the rest of the labs.
Absolutely, yeah. Some bedside observations
will be good.
Again, take it all in the clinical picture
of what they’ve given you to examine. So,
that’s fine. You can sit out. Thank you
very much. I remember when I have my finals,
you tend to get patients that are stable or
have fixed conditions that their signs can be
replicated over and over. I remember revising
a lot about colostomies and ileostomies and
things. In our actual exam, we end up getting
a peritoneal dialysis catheter. So it’s
just being able to recognize and comment on
the health of it. Does it look clean? Is there
any odor? What does the skin look like around
it? Is it cellulitic? Does the abdomen look
distended? And it’s just picking upon those
kinds of cues. He also had a scar as well
in the flank. So it’s important to make
sure you’re looking at the flanks as well.
Did you do the full abdomen exam?
Say that again?
At that station, did you do a full abdomen
Yes. So, you can just stand into the bed and
say, “I’m going to comment on the most
obvious thing.” I can see it as a tube coming
out of this part of the abdomen, but I’m
going to go through systematic just to make
sure I don’t miss anything and it’s just
a tick in the box to show that yeah you picked
from the obvious thing. But don’t let it
throw you because that was the thing when
you see a colostomy bag, it’s something
like, “I know what it is and I know what’s
going on” but just make sure you don’t
miss anything else. Are you guys happy?
What do you do in the full abdomen exam, does
that stuff include JVP?
You can do. What would you do when you examine
Position the patient to 45 degrees and turn
the head to the left and get a good light
source and feel the veins.
Absolutely. What’s the other thing you can
do to make --
Press on the liver. Exactly! So you just
make sure in that as
well that you’re asking them, are you
tender at all and I’m going to push in your
tummy. So the salient point for an abdomen
exam is make sure you’re exposing the patient
appropriately. Make sure that the patient
is lying flat. I remember in one exam that
a friend did at different university. They
had the patient at 45 degrees inclining and you had
to go in and put the patient flat. The other
thing is when you palpate in the abdomen,
make sure that you’re on the patient’s
level and you’re looking at the patient’s face.
Just be really systematic, okay? Just
make it look like you’ve done it a million
times before. So for shifting dullness,
you start at the
umbilicus? So you start at the umbilicus
and you go down.
You’re trying to demonstrate. So if you
imagine you’ve got fluid, it’s going to
sit in the flanks. So you’re going from
resonant, resonant, resonant into the fluid
level. That’s where it becomes dull. So you keep
your finger on that and get the patient
to roll over to the side.
Far away from you.
Well, yeah, they’d have to roll away from
you. So if you want them to roll towards you,
you percuss the other side over the patient.
Roll towards you, wait for 30 seconds, and
then re-percuss. So what additional information
reflex give you? In terms of the JVP, if you
think about the
blood supply going back to the heart, you
have a lot of venous reserve in the liver.
So when you’re pushing on that, you’re
increasing the venous return. So the idea
being that you might make a JVP that’s otherwise
not visible to be more prominent.
What would that be, normal or abnormal?
It’s in the context of the patient. So say
if you’re the patient that had a heart condition,
that might not result in any rise in the JVP.
But if you’ve got a patient that’s dehydrated
and you’re able to increase the venous return
to the heart, you might see that that’s
raised, so in dehydrated patient that would
cause a rise. It shouldn’t cause a rise in
a normal patient?
It will do. But if someone has got an incompetent
valve no matter how much blood you’re pushing
back into the heart, the amount, the cardiac
output is not going to be affected by whatever you effort is.
Does that make sense? I don't understand.
It doesn’t make sense
at all. Okay. So your cardiac output
is your stroke
volume. So the volume of blood that’s in
your ventricle times by your heart rate.
So when you’re looking at the JVP, you’re
not necessarily getting the patient’s heart
to work any faster but you are trying
to increase the amount of blood that’s going
back in. If you’ve got an incompetent valve,
so every time the ventricle beats it opens
up, but it is not closing and stopping the
blood from flowing back. You might get a lot
of blood coming up, but it would drop very
quickly. Does that make sense to you? Do you
necessarily see the JVP rising in the
It makes sense but now it doesn’t make sense
why you do it and do the reflex in the abdo
exam because if you can’t see it and then
you push on the abdomen and you can see it,
what’s the significance of that? Is it actually
raised or you’re just showing that it can
be raised by you pushing on this?
It can give you an idea about the patient’s
fluid status. And if you think that someone
has got a lot of hepatomegaly because it’s
now either you got a lot of venous storage
of blood. That might give you an idea that
the liver is enlarged as well. It’s not
directly related to an abdo exam which is
why I don’t always do when I do my abdo exam.
So in a normal person, when you press on the
abdomen, it wouldn’t raise as much?
If you have someone that is otherwise normal,
you push on the liver, the JVP will go up.
Okay. If you’ve got a patient with dehydration,
you might not see the JVP to begin with and
you push on the liver, it might go up a little
bit, because you’re increasing that cardiac
return to the heart. So you’ve got an increased
volume that’s coming out of the ventricles.
If you’ve got a patient that is otherwise,
what was the other question?
Normal. Yeah. If a patient is otherwise
you do that, you will get a rise but it’s just
demonstrating that perhaps if you couldn’t
see it first, you are doing something to make
it more prominent. I hope that makes sense.
Yeah, I understand it to be a way of making
it more easy to say rather than any pathological --
It’s all in the clinical context
you’re examining the patient. So don’t
get too hung up about it.
Back to ascites, shifting dullness,
is it alright to do that or do you have to
do the fluid thrill thing as well?
You can do the fluid thrill. Shall we? Do you want to
I can’t remember how to do that.
Okay. So, what I’m going to ask you to do
is I’m just going to have to tap on your
tummy. But if I can borrow your hand, just
get you to place that across your tummy, what
I’m going to do is I’m going to flick
on one side of your tummy and I’m going
to put a hand on the other side. So, what
am I doing? That’s fine.
You can get the patients to do that.
Exactly. Sit up for me. So, what you’re
doing is essentially when you’re tapping one
side, you are just stopping any skin conduction
by putting that hand there and you’re checking
to see whether or not that pulse is being
transmitted through the underlying fluid.
But again, take it in the context. If someone
has obviously got ascites, that somebody has
got a massive amount of tense ascites.
So you might have a small ascites that you might
necessarily be able to demonstrate a fluid
thrill on, but you might be able to demonstrate
shifting dullness on.
I have a quick question about hepatomegaly.
I’ve read different things in different
books. Some people would say that it’s better
to feel in for the liver when they’re breathe
in. Yeah. And then some people say
that when you
breathe out, your lungs fill with air so they
push the liver down. So, that means you should
do it when they breathe out because then you’ll
feel the liver hitting your hand. So I wasn’t
too sure which one –
When you breathe in your lungs fill with air.
Oh yeah. But I’ve read two different things
in the book.
No. I can see why you’re confused. I thought
you want to be in there when they
take a breath. As they’re taking a breath
in and you’re
pushing in and you’re supposed to be putting
your hand a third down so you can feel that
long-edge passing as they’re taking a breath
in. Does that make sense?
So not when they’re breathing out?
When they’re breathing out, that liver is
just moving about. So you might potentially
catch the edge of it but it’s much easy
to feel something going in that direction.
Yeah, breathing in pushes it down. Okay.
That’s fine. I think you meant like in
the book, like you push in
and keep your hands still while they
breathe out and then you might feel it hitting
your hand. Yeah. Maybe that’s probably it.
for them to breathe out and then leave
And then when they breathe in, yeah. But you’re
trying to like meet it.
In clinical practice, I don’t really do
that because I don’t find it very accurate.
So, what I tend to do is, have you heard of
a scratch test, which I don’t know what
are you doing in your exams. Can I get you
to lie down again for me? I remember one of
my consultants teaching me this. You probably
don’t do this because you are really young.
But if you’ll imagine the train track and
someone is tapping on one side because that
transmission is going through the train track.
You can feel it further down. It’s the same
principle. So because all of this is air
got a rib overlying a relatively dense structure
like the liver, what you can do is if you
take your stethoscope, feel for the bottom
part of the rib and you put your stethoscope
on. If you kind of scratch up when you notice
that you can hear the scratching.
That’s the liver edge.
Yes, he did.
He still teaches that.
I think that’s the most useful thing that
I’ve done because I find it quite difficult
to palpate out livers. And if you’re tapping
for shifting dullness,
do you have to be parallel to the bed of your
finger going down? Because a lot are doing
it like that but is it the correct way to
do like that?
Say that again. So, why not --
Your finger, the one that you have on the
abdomen must be parallel to the counter base.
Because if I’m doing it that way, I’ll
give you an exam and I could say, “Well,
how do you know that it’s not the tip of
your phalanx rather than down here where you’re
feeling the percussion note?” So yeah, it
needs to be parallel. It’s fine. You can
get up again.
I think it was about the liver. See, you need
to be tapping out the borders, and how big should
the liver actually be?
You tell me, how big should it be.
Four fingerbreadths, about 10-12 cm. Above the costal margin.
Where does your liver start in your chest?
Yeah, it’s about your
sixth anterior but it’s around T4. So it
goes really -- Tell me why we have to tap
it out from the
top because if it’s a woman, it’s difficult
Again, it’s different to what you do in
clinical practice, but ideally yeah you’re supposed
to tap it out and I always start on the chest,
go down. It’s unlikely you’re going to
get woman for an abdo exam if it’s something
that you need to percuss out anyway. So if
you percuss it down you’ll go from resonant
resonant resonant because you’re going lung,
lung, lung. Then when you get to liver, you’ll
notice the percussion note changes.
Spleen has to be three times its normal size
to be palpable. The liver even in thin persons,
can you feel it and know pathology? Someone
told me that even in thin persons you'll never
feel the liver unless there’s something wrong,
but I seem to find that you can feel it --
I’ve felt it in people that are
otherwise well. Okay. Thank you.