​

1. Wash your hands
2. Introduce yourself and thank the patient

Ensure patient is at 45 degree

1. Inspect the room for devices, fluid infusions, oxygen therapy etc
2. Inspect fingers
   1. Leukonychia - white nails, a sign of hypoalbuminaemia, seen in chronic liver disease, nephrotic syndrome
   2. clubbing - seen in IBD, CLD, congenital heart disease, CF
3. Inspect hands
   1. palmar erythema - reflects vasodilated state of cirrhosis secondary to increased oestrodiol: free testosterone
   2. dupytren's contracture
   3. tendon xanthoma
4. Check for hepatic flap
   1. Ask patient to dorsiflex wrist with fingers spread apart
   2. asterixis is found in all grades of hepatic encephalopathy, and is not specific (eg metabolic, uraemic encephalopathies)
5. Whilst checking for hepatic flap determine orientation
   1. Which hospital they are at
   2. What day of the week is it
6. Inspect arms
   1. brusing, ecchymoses, marks of excoriation from pruritis, track marks, tatoos, A-V fistula, cachexia, jaundiceK-F
7. Ask for blood pressure and temperature and repeat it back to examiner
8. Look into eyes
   1. Jaundice
   2. K-F rings
   3. Xantholesma
   4. Arcus-senilis
   5. scleritis, episcleritis, anterior uveitis
9. Look into mouth
   1. appreciate fetor hepaticus
   2. Look for telangiectasia
   3. ulcers
   4. dentition
   5. gum hypertrophy (CsA use in liver/ renal Tx)
   6. glossitis
   7. angular chelitis
10. Palpate the parotids
11. Palpate supraclavicular lymphadenopathy
    1. look for virchow's node on the left
12. Check JVP and feel for hepato-abdominal reflex 
    1. evidence of congestive hepatic cirrhosis
13. Palpate for gynecomastia
14. Lie patient flat
15. Ask the patient to lift their head of the bed, looking for hernias
16. Make a point of observing from top and from sides, trace out scars clearly for examiner
17. Ask if there is any tenderness
18. Palpate superficially
19. Palpate deeply
20. Palpate from RIF for liver and tract liver edge, noting whether it is firm/ irrergular etc
21. Measure liver span by finding the superior surface through percussion
22. Palpate for spleen from RIF
23. Percuss for spleen and note its contour
24. Percuss for shifting dullness towards you and make a note of position of dullness
25. Turn pt to right hand side and palpate for spleen if not felt earlier, otherwise wait 30s and look at back whist waiting for shifting dullness
26. Percuss for shifting dullness
27. Ballot kidneys
28. Auscultate for hepatic venous hum, bruit, renal artery bruit, bowel sounds
29. Ask the patient to look at the groin for hernias and palpate for inguinal lymphadenopathy
30. Thank the patient
31. Turn to examiner and say that you would like to assess for testicular atrophy, perform a PR examination for malena and masses, and note the results of the urinalysis
32. Request to present your findings