Examination checklist

    Abdominal examination

    The 26-step abdominal mark sheet, how to measure and present organs, and the patterns — hepatosplenomegaly, ascites, massive spleen — that examiners expect you to name.

    Internal Medicine
    Abdomen
    All colleges

    Mark sheet

    26 steps · 26 marks

    #StepWellPartlyNot
    1. 1Greets the examiner1½0
    2. 2Greets the patient, introduces self and obtains consent1½0
    3. 3Ensures privacy with a screen or chaperone1½0
    4. 4Cleans hands1½0
    5. 5Exposes from the nipples to the upper thighs, keeping the genitalia covered1½0
    6. 6Inspects at eye level from the foot of the bed1½0
    7. 7Inspects at eye level from the side of the bed1½0
    8. 8Looks across to inspect the far (left) side of the abdomen1½0
    9. 9Uses a light to look for dilated veins, swellings and the hair pattern1½0
    10. 10Checks the hernial orifices for a cough impulse1½0
    11. 11Asks where it hurts before touching1½0
    12. 12Palpates lightly in every region while watching the face1½0
    13. 13Palpates deeply for masses1½0
    14. 14Palpates for the liver from the right iliac fossa with breathing, knees bent1½0
    15. 15Measures how far the liver extends below the costal margin1½0
    16. 16Percusses the upper and lower borders to give the liver span1½0
    17. 17Palpates for the spleen from the right iliac fossa with breathing, then with the patient rolled towards the examiner1½0
    18. 18Percusses for splenic dullness1½0
    19. 19Measures the size of the spleen1½0
    20. 20Ballots both kidneys bimanually1½0
    21. 21Tests for shifting dullness or a fluid thrill1½0
    22. 22Listens for bowel sounds1½0
    23. 23Listens for renal bruits1½0
    24. 24Listens for a bruit over the liver1½0
    25. 25Asks to perform a rectal examination1½0
    26. 26Examines for signs of chronic liver disease — hair, pallor, jaundice, xanthelasma, lymph nodes, axillary hair, palmar erythema, small muscle wasting, Dupuytren's contracture, clubbing, gynaecomastia, spider naevi, oedema1½0

    Summary of findings

    Say what you saw, what you felt, and what the organs measured — then name the pattern and its likely cause and complications.

    I examined the abdomen of a middle-aged man who is jaundiced. The abdomen is uniformly distended and moves with respiration, with dilated superficial veins radiating from the umbilicus. It is not tender. The liver is not palpable and the span is reduced to 6 cm. The spleen is palpable 8 cm below the left costal margin, firm and smooth. There is shifting dullness. The kidneys are not ballotable, bowel sounds are normal and there are no bruits. He has palmar erythema, spider naevi and gynaecomastia. These findings are in keeping with decompensated chronic liver disease with portal hypertension.

    • Liver: centimetres below the right costal margin in the midclavicular line, plus the percussed span; consistency, surface, edge, tenderness, bruit
    • Spleen: centimetres below the left costal margin, measured towards the right iliac fossa along its line of enlargement; consistency; whether you felt a notch
    • Ascites: how you showed it — shifting dullness for moderate, fluid thrill for tense

    Differential diagnoses

    PatternCauses to offer
    Hepatomegaly with ascitesHepatocellular carcinoma, metastases, right heart failure, Budd–Chiari syndrome, abdominal tuberculosis
    Shrunken liver, splenomegaly and ascitesCirrhosis with portal hypertension — hepatitis B or C, alcohol, autoimmune, metabolic, herbal and drug injury
    Massive splenomegalyChronic myeloid leukaemia, myelofibrosis, hyperreactive malarial splenomegaly, visceral leishmaniasis, lymphoma
    Hepatosplenomegaly without ascitesMalaria, lymphoma and leukaemia, haemoglobinopathies, HIV, schistosomiasis
    Bilateral ballotable massesPolycystic kidneys, bilateral hydronephrosis, amyloidosis

    More detail: Massive splenomegaly, Hard nodular hepatomegaly with ascites, Shrunken liver with ascites, and Liver tests and treatment by cause.

    Investigations

    • Blood: full blood count and film, liver function with albumin and INR, urea, electrolytes and creatinine, glucose
    • Viral and immune markers: HBsAg, anti-HCV, HIV test with consent, autoantibodies where relevant
    • Tumour markers: alpha-fetoprotein
    • Imaging: abdominal ultrasound with Doppler; contrast CT or MRI for a mass
    • Ascitic tap: cell count, albumin for the serum-ascites albumin gradient, protein, culture, cytology, ADA
    • Endoscopy: for varices in portal hypertension

    Treatment

    • Treat the cause: antivirals for hepatitis B or C, stopping alcohol, specific treatment of blood disorders
    • Ascites: salt restriction, spironolactone with or without furosemide, paracentesis with albumin
    • Prevent and treat complications: variceal bleeding, spontaneous bacterial peritonitis, encephalopathy
    • Nutrition, vaccination, avoiding NSAIDs and herbal remedies

    Examiner questions

    References

    • Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, et al., eds. Harrison's Principles of Internal Medicine. 22nd ed. New York: McGraw Hill; 2025.

    Updated September 18, 2026