- 🧼 Preparation (WIPER): Wash hands, Introduce yourself, gain Permission/consent, Explain, ensure patient exposure (abdomen from nipples → pubis), offer chaperone, and position flat (or 45° if breathless).
- 👀 End-of-bed Inspection:
- Patient: cachexia, jaundice, pallor, pigmentation, stigmata of CLD (ascites, encephalopathy, muscle wasting).
- Environment: NG tube, stoma bags, IV fluids, nutritional supplements, paracentesis drains, CAPD devices.
- ✋ Hands & Arms:
- Clubbing (IBD, cirrhosis, malignancy).
- Leukonychia (hypoalbuminaemia), koilonychia (iron deficiency).
- Palmar erythema, Dupuytren’s contracture, flapping tremor (hepatic encephalopathy).
- Scratch marks (pruritus from cholestasis).
- Check pulse: rate, rhythm, character (bounding in aortic regurgitation, AF in hyperthyroidism → malabsorption).
- 🫀 Neck & Face:
- JVP (fluid overload, Budd–Chiari).
- Virchow’s node (Troisier’s sign → gastric cancer metastasis).
- Eyes: conjunctival pallor (anaemia), jaundice, xanthelasma, Kayser–Fleischer rings (Wilson’s).
- Mouth: glossitis, angular stomatitis, aphthous ulcers (IBD, coeliac), poor dentition, fetor hepaticus (severe liver failure).
- 👕 Inspection of Chest & Abdomen:
- Chest: spider naevi, gynaecomastia, hair loss, scars (thoracotomy, chest drains).
- Abdomen: scars (laparotomy, transplant, laparoscopic), striae, distension (5 F’s: fat, fluid, flatus, faeces, fetus), caput medusae, herniae, visible peristalsis, pulsations.
- 🤲 Palpation: (kneel, watch patient’s face)
- Superficial → tenderness, rebound, guarding, rigidity, masses, hernia orifices.
- Deep → liver edge (smooth, irregular, tender), spleen tip (must palpate diagonally), kidneys (ballotable), aorta (expansile pulsation for aneurysm).
- Special signs: Murphy’s (cholecystitis), ballot kidneys, renal angle tenderness.
- 🥁 Percussion:
- Liver span (mid-clavicular line, 6–12 cm normal).
- Spleen (Traube’s space percussion or Nixon’s method).
- Shifting dullness & fluid thrill → ascites.
- Bladder percussion for retention if indicated.
- 🎧 Auscultation:
- Bowel sounds (increased in obstruction, absent in ileus/peritonitis).
- Renal/aortic bruits (renal artery stenosis, AAA).
- 🦵 Other Systems:
- Check for peripheral oedema (nephrotic syndrome, cirrhosis, portal hypertension).
- Sacral oedema if immobile.
- Look at lower limbs for muscle wasting, bruising, pigmentation.
- 🙏 Closure: Thank patient, cover them up, wash hands.
Present findings systematically, then suggest further tests:
- Bedside: stool chart, urine dip, ascitic tap.
- Bloods: FBC, LFT, U&E, CRP, coagulation, viral hepatitis screen, autoimmune screen.
- Imaging: CXR, abdominal US/CT, endoscopy, colonoscopy.
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