Complete Abdominal Examination

Candidate instructions

Acute right-lower-quadrant abdominal pain station

Your task

Perform a focused abdominal examination on a 24-year-old patient with 14 hours of abdominal pain that began around the umbilicus and has moved to the right lower quadrant. At the end, present your findings, leading diagnosis, prioritized differential, targeted investigations, immediate management and safety-netting. You have 11 minutes.

Information available at entry

HR 104/minBP 118/72 mm HgRR 18/minSpO₂ 99%Temp 38.1°C

Safety priority: Before a routine examination, identify shock, sepsis, severe uncontrolled pain or generalized peritonitis. If the patient is unstable, stop the routine sequence, initiate ABC assessment and resuscitation, obtain urgent senior/surgical help and do not delay care for a complete examination.

What examiners expect

Introduction, two identifiers, explanation, consent, hand hygiene and pain assessment.
Appropriate supine positioning and respectful abdominal exposure.
Correct abdominal order: inspection, auscultation, percussion and palpation.
Palpation beginning away from the painful area and gentle assessment for peritonism.
Selective special tests rather than repeated painful maneuvers.
Recognition of a focal right-lower-quadrant/peritoneal pattern.
Pregnancy assessment in anyone who could be pregnant before imaging or definitive planning.
Concise synthesis, prioritized differential, investigations, management and explicit escalation criteria.

Timed rehearsal

Run the complete station in 11 minutes

Aim to finish patient contact by about 9 minutes and reserve the final 2 minutes for findings, differential, investigations, management and safety-netting.

Open Station 7 Review procedure

Station time

11:00

Ready for an 11-minute attempt.

Complete procedure

Exact 11-minute abdominal examination sequence

Use this as a rehearsal structure, not a rigid ritual. Modify or stop immediately when pain, instability or peritonitis requires urgent care.

0:00–0:30

1. Immediate stability and pain check

Say: “Before I begin, are you feeling faint, very weak, short of breath, or is the pain suddenly becoming much worse?”

Review heart rate, blood pressure, temperature, respiratory rate and mental status.
Look for pallor, diaphoresis, severe distress, shock or sepsis.
Escalate immediately if unstable.

0:30–1:10

2. Introduce, identify, explain and consent

Say: “Hello, my name is ____, one of the clinical candidates. Could I confirm your full name and date of birth? I have been asked to examine your abdomen. I will look, listen, tap and gently feel your abdomen. Is that okay?”

Confirm two identifiers.
Explain the examination in plain language.
Obtain consent.
Offer a chaperone if an intimate examination may become necessary.

1:10–1:40

3. Hand hygiene, position and exposure

Say: “I will clean my hands. Please lie flat if comfortable, with your head supported. I will expose only the area from the lower chest to the groin while keeping you covered as much as possible.”

Perform hand hygiene.
Ask where the pain is worst before touching.
Position supine with knees relaxed if helpful.
Expose xiphoid to pubic region appropriately while preserving warmth and dignity.

1:40–2:10

4. General inspection

Say: “I am first looking for signs that you are unwell and for clues to the cause of the pain.”

Assess distress, stillness versus writhing, hydration and colour.
Look for jaundice, pallor and dehydration when relevant.
Note IV lines, drains, stomas, emesis or other bedside clues.

2:10–2:55

5. Inspect the abdomen

Say: “I am inspecting the abdomen for swelling, scars and abnormal movement.”

Observe contour and symmetry.
Look for distension, scars, striae, bruising, masses, hernias and visible peristalsis or pulsation.
Note guarding or reluctance to move.

2:55–3:40

6. Auscultate before percussion or palpation

Say: “Before I press on your abdomen, I am going to listen with my stethoscope.”

Listen for bowel sounds without overinterpreting a brief sample.
Listen for bruits only when clinically relevant.
Do not delay urgent treatment to characterize bowel sounds in an obviously unstable patient.

3:40–4:30

7. Percuss systematically

Say: “I will gently tap across your abdomen. Please tell me immediately if it is painful.”

Percuss all quadrants for tympany and dullness.
Use gentle percussion tenderness as a less provocative way to assess peritoneal irritation.
Assess liver span or shifting dullness only if the clinical question requires it.

4:30–5:45

8. Light palpation — start away from pain

Say: “I will start away from the painful area and press gently. Please tell me if anything hurts.”

Warm hands and watch the patient’s face.
Palpate all quadrants systematically, leaving the painful area until last.
Assess tenderness, voluntary or involuntary guarding and masses.
Do not repeatedly press the most painful point.

5:45–6:35

9. Deep palpation and organ assessment when tolerated

Say: “If you are comfortable, I will press a little more deeply to feel for any swelling or enlarged organs.”

Deep palpate only as tolerated.
Assess liver and spleen when relevant.
Consider kidneys/aorta only when indicated and safe.
Skip deep palpation if there is marked guarding or obvious peritonitis.

6:35–7:35

10. Focused right-lower-quadrant and peritonism assessment

Say: “I am going to check the painful area once, gently. Please tell me if the pain increases.”

Identify maximal RLQ tenderness and localized guarding.
Use cough or percussion tenderness to assess peritoneal irritation.
Rovsing, psoas or obturator maneuvers may be used selectively if they add diagnostic value.
Repeated rebound testing is unnecessary and may cause avoidable pain.

7:35–8:20

11. Complete focused adjacent systems

Say: “I would complete the examination with a few focused checks depending on the suspected cause.”

Check costovertebral-angle tenderness if urinary pathology is possible.
Inspect groins for hernia if suggested by symptoms.
Perform pelvic or rectal examination only when clinically indicated, after specific consent and with a chaperone.
Consider cardiopulmonary examination when referred pain or systemic illness is possible.

8:20–8:50

12. Restore comfort and close the examination

Say: “Thank you. I am finished examining your abdomen. I will help you get comfortable and covered again.”

Re-cover and reposition the patient.
Clean hands.
Acknowledge discomfort and ensure analgesia has not been delayed.

8:50–11:00

13. Present, investigate, manage and safety-net

Say to examiner: “This patient has focal right-lower-quadrant tenderness with localized guarding and percussion/cough tenderness, suggesting localized peritoneal irritation. Acute appendicitis is most likely. I must urgently exclude pregnancy-related and gynecologic emergencies and assess for perforation or sepsis.”

State the leading diagnosis and dangerous alternatives first.
Choose pregnancy testing, blood/urine tests and tailored imaging.
State NPO, analgesia, antiemetic, IV fluids as needed and early surgical consultation.
Give explicit deterioration and escalation criteria.

Finding interpretation

Model findings: localized appendicitis pattern

Do not invent findings in the exam. Use only the findings supplied by the examiner or standardized patient.

General

Uncomfortable and prefers to remain still.
HR 104/min, temperature 38.1°C.
No hypotension or altered mental status.

Abdomen

No marked distension.
Maximal right-lower-quadrant tenderness.
Localized guarding.
Percussion/cough tenderness.
No generalized board-like rigidity.

Relevant negatives

No costovertebral-angle tenderness.
No generalized peritonitis.
No obvious hernia.
Pelvic examination reserved for clinical indication.

Model presentation: “This is a 24-year-old patient with focal right-lower-quadrant tenderness, localized guarding and percussion/cough tenderness, with fever and mild tachycardia but without shock or generalized rigidity. The examination localizes the process to the right lower quadrant with localized peritoneal irritation. In the clinical context of migratory periumbilical-to-RLQ pain, appendicitis is most likely.”

Clinical reasoning

Prioritized differential diagnosis

Prioritize by probability and danger, not by producing a long unranked list.

Priority	Diagnosis	Why it matters	Discriminating clues
1	Acute appendicitis	Most likely; may progress to perforation, abscess or sepsis.	Migratory pain, anorexia/nausea, fever, focal RLQ tenderness and localized peritonism.
2	Ectopic pregnancy	Potentially fatal hemorrhage; must be excluded in anyone who could be pregnant.	Pregnancy possibility, amenorrhea, vaginal bleeding, pelvic pain, syncope or shock.
3	Ovarian torsion	Time-sensitive threat to ovarian viability.	Sudden unilateral pelvic pain, vomiting, adnexal tenderness/mass.
4	Perforation/generalized peritonitis	Requires urgent resuscitation and surgical management.	Diffuse severe pain, rigid abdomen, shock, sepsis or free air.
5	PID / tubo-ovarian infection	Important reproductive and infectious complication.	Discharge, cervical motion/adnexal tenderness, STI risk, fever.
6	Renal colic / UTI / pyelonephritis	Common mimic with different treatment pathway.	Flank-to-groin pain, urinary symptoms, hematuria or CVA tenderness.
7	Crohn disease / terminal ileitis	Can mimic appendicitis and may affect operative planning.	Chronic diarrhea, weight loss, previous episodes, extraintestinal features.
8	Gastroenteritis or other bowel inflammation	Common but should not be used to dismiss focal peritonism.	Prominent diarrhea, sick contacts, diffuse cramping rather than progressive focal tenderness.

Targeted work-up

Investigations and why you need them

A strong NAC answer links each test to a diagnostic, treatment or safety decision.

Investigation	Purpose	Priority
Repeat vital signs and clinical reassessment	Detect evolving sepsis, shock, worsening peritonitis or treatment response.	Immediate
Urine or serum β-hCG when pregnancy is possible	Exclude pregnancy-related emergencies and guide imaging/consultation choices.	Immediate
CBC ± CRP	Support inflammatory assessment; normal values do not by themselves exclude appendicitis.	Early
Electrolytes, urea/creatinine and glucose	Assess dehydration, renal function and readiness for imaging/operative care.	Early
Urinalysis	Evaluate urinary mimics; mild pyuria/hematuria can occur with adjacent inflammation.	Early
Liver tests and lipase	Use when upper-abdominal, hepatobiliary or pancreatic alternatives are plausible.	Targeted
Ultrasound	Useful when pregnancy/gynecologic pathology is possible and in settings where radiation avoidance is important.	Targeted/early
CT abdomen/pelvis with appropriate contrast protocol	High diagnostic accuracy in nonpregnant adults when diagnosis remains uncertain or complications/alternatives must be defined.	Targeted
Lactate, blood cultures, type and screen	Use when sepsis, shock, perforation or significant bleeding/operative risk is suspected.	Urgent when indicated

Imaging principle: Do not order imaging as a reflex. Integrate pregnancy status, age, examination findings, diagnostic uncertainty, local pathways and whether delay would be unsafe. Current appendicitis guidelines support risk stratification plus selective imaging rather than a single test for every patient.

Immediate plan

Management, disposition and safety-netting

State management in a safe sequence. Medication selection and dosing must follow the patient’s condition and local protocols.

1. Stabilize and relieve symptoms

ABCDE assessment if unstable.
Keep NPO while urgent surgical disease is being evaluated.
Provide prompt analgesia and antiemetic therapy.
IV access and isotonic fluid when dehydrated, septic or unable to maintain intake.
Repeat vital signs and abdominal examination as clinically appropriate.

2. Treat the likely cause

Request early surgical consultation for suspected appendicitis with peritoneal findings.
Use antibiotics according to the appendicitis/intra-abdominal infection pathway, especially when complicated disease is suspected.
Definitive treatment may include laparoscopic appendectomy; selected uncomplicated cases may be considered for nonoperative antibiotic management under an appropriate surgical/shared-decision pathway.
Involve gynecology urgently if ectopic pregnancy or torsion is possible.

3. Disposition and reassessment

Do not discharge a patient with worsening pain, evolving peritonism, sepsis or unresolved high-risk diagnosis.
Escalate promptly for hypotension, rising tachycardia, generalized rigidity, worsening fever, syncope or altered mental status.
If discharge is appropriate after senior review and diagnostic uncertainty remains low, provide explicit return precautions and follow-up.

Urgent escalation: shock, generalized peritonitis, rapidly worsening pain, persistent vomiting with dehydration, sepsis, suspected perforation, ruptured ectopic pregnancy or ovarian torsion requires immediate senior/emergency/surgical/gynecologic assessment.

High-yield NAC phrasing: “I would not delay analgesia, resuscitation or surgical assessment to complete repeated painful abdominal maneuvers.”

Linked learning pathway

Continue through abdominal and acute-surgical practice

Use the master examination page together with the integrated 11-minute stations and clinical modules.

11-minute station

Reference starting points

Educational preparation only. Clinical care must follow current patient-specific assessment and local protocols.

Acute right-lower-quadrant abdominal pain station

What examiners expect

Run the complete station in 11 minutes

Exact 11-minute abdominal examination sequence

1. Immediate stability and pain check

2. Introduce, identify, explain and consent

3. Hand hygiene, position and exposure

4. General inspection

5. Inspect the abdomen

6. Auscultate before percussion or palpation

7. Percuss systematically

8. Light palpation — start away from pain

9. Deep palpation and organ assessment when tolerated

10. Focused right-lower-quadrant and peritonism assessment

11. Complete focused adjacent systems

12. Restore comfort and close the examination

13. Present, investigate, manage and safety-net

Model findings: localized appendicitis pattern

General

Abdomen

Relevant negatives

Prioritized differential diagnosis

Investigations and why you need them

Management, disposition and safety-netting

1. Stabilize and relieve symptoms

2. Treat the likely cause

3. Disposition and reassessment

Complete abdominal examination checklist

Continue through abdominal and acute-surgical practice

Acute RLQ abdominal pain

Upper gastrointestinal bleeding

First-trimester pain and bleeding

Physical Examination

Surgery & Perioperative Care

OSCE Skills Frameworks

Reference starting points