Examination checklist

    Surgical abdominal examination

    A 26-step mark sheet for the surgical abdomen — scars, masses, organomegaly, peritonism, hernial orifices, external genitalia and rectal examination — with how to describe an abdominal mass and which organ it arises from.

    Surgery
    Abdomen and hernias
    All colleges

    Mark sheet

    26 steps · 26 marks

    #StepWellPartlyNot
    1. 1Greets the examiner and the patient, introduces self, obtains consent and offers a chaperone1½0
    2. 2Cleans hands and positions the patient flat with one pillow, arms by the sides1½0
    3. 3Exposes from the nipples to the knees, covering the genitalia until they are examined1½0
    4. 4Performs a brief general examination — pallor, jaundice, hydration, nutrition, lymph nodes including the left supraclavicular fossa1½0
    5. 5Inspects from the foot of the bed — distension, symmetry, visible masses, visible peristalsis1½0
    6. 6Inspects closely for scars, stomas, drains, sinuses, dilated veins, striae and skin changes1½0
    7. 7Asks the patient to cough and raise the head to show hernias and divarication1½0
    8. 8Checks movement of the abdomen with respiration1½0
    9. 9Asks where the pain is and starts palpation away from it, watching the face1½0
    10. 10Palpates lightly in all nine regions for tenderness, guarding and rigidity1½0
    11. 11Tests for rebound or percussion tenderness gently if peritonitis is suspected1½0
    12. 12Palpates deeply for masses1½0
    13. 13Describes any mass — site, size, shape, surface, edge, consistency, tenderness, mobility, movement with respiration, and whether one can get above or below it1½0
    14. 14Palpates the liver and gallbladder, and tests Murphy's sign1½0
    15. 15Palpates the spleen1½0
    16. 16Ballots both kidneys bimanually1½0
    17. 17Palpates the aorta for an expansile pulsation1½0
    18. 18Percusses the mass and organs, and tests for shifting dullness1½0
    19. 19Percusses the suprapubic region for a distended bladder1½0
    20. 20Auscultates for bowel sounds (character — absent, normal, tinkling) and a succussion splash1½0
    21. 21Auscultates for bruits over the aorta and renal arteries1½0
    22. 22Examines the hernial orifices standing, with cough impulse1½0
    23. 23Examines the external genitalia1½0
    24. 24Asks to perform a digital rectal examination, and offers proctoscopy and sigmoidoscopy1½0
    25. 25Offers to examine the chest and legs, and to test the urine1½0
    26. 26Presents the findings with a diagnosis and differentials1½0

    Summary of findings

    I examined the abdomen of a 60-year-old man who is pale and thin. There are no stigmata of chronic liver disease, and there is no left supraclavicular node. The abdomen is not distended and moves with respiration, with no scars. There is a 6 × 5 cm mass in the right iliac fossa. It is non-tender, hard, with an irregular surface and ill-defined edge. I can get below it but not above it. It does not move with respiration and has limited side-to-side mobility. It is dull to percussion, and bowel sounds are normal. The liver, spleen and kidneys are not palpable, and there is no ascites. The hernial orifices and external genitalia are normal. I would like to complete my examination with a digital rectal examination. The most likely diagnosis is carcinoma of the caecum.

    Where is the mass from?

    OrganCharacteristic features
    LiverRight upper quadrant, moves with respiration, cannot get above it, dull to percussion, extends across the midline
    GallbladderTip of the ninth costal cartilage, smooth, pear-shaped, moves with respiration
    SpleenLeft upper quadrant, moves towards the right iliac fossa, notch, cannot get above it, dull, not ballotable
    KidneyBallotable, can get above it, resonant (bowel in front), moves slightly with respiration
    Stomach, pancreas, transverse colonEpigastric, may transmit aortic pulsation, may be fixed
    Caecum or appendix massRight iliac fossa; can get below it (inguinal ligament)
    Bladder, uterus, ovarySuprapubic, cannot get below it, dull
    AneurysmEpigastric or umbilical, expansile

    Differential diagnoses

    Mass siteCauses to offer
    Right iliac fossaCarcinoma of the caecum, appendix mass or abscess, ileocaecal tuberculosis, Crohn's disease, amoeboma, ovarian mass, transplanted kidney, psoas abscess, iliac lymph nodes
    Left iliac fossaSigmoid carcinoma, diverticular mass, faeces, ovarian mass
    EpigastriumGastric carcinoma, pancreatic carcinoma or pseudocyst, transverse colon carcinoma, aortic aneurysm, left lobe of liver
    Right upper quadrantHepatomegaly, gallbladder, right kidney, hepatic flexure carcinoma
    Left upper quadrantSplenomegaly, left kidney, splenic flexure carcinoma, gastric carcinoma
    SuprapubicBladder (retention), uterus (pregnancy, fibroids), ovarian cyst

    See Carcinoma of the caecum and Appendix mass.

    Investigations

    • Blood: full blood count, U&E, liver function, CRP, clotting, group and save, tumour markers when relevant (CEA, CA 19-9, AFP)
    • Urine: dipstick, pregnancy test
    • Imaging: ultrasound; contrast CT of the abdomen and pelvis (and chest for staging); erect chest X-ray for free gas
    • Endoscopy: upper GI endoscopy, colonoscopy with biopsy

    Treatment

    • Resuscitate the acute abdomen first
    • Treat according to the cause — see the linked case presentations

    Examiner questions

    References

    • O'Connell PR, McCaskie AW, Sayers RD, eds. Bailey & Love's Short Practice of Surgery. 28th ed. Boca Raton: CRC Press; 2023.

    Updated September 18, 2026