EXAMINATION OF THE ABDOMEN

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 General Considerations
• The patient should have an empty bladder

• The patient should be lying supine on the exam table that

is at a comfortable height for both of you.

• At this point, the patient should be appropriately draped.

• The patient's hands should remain at their sides with their

heads resting on a pillow.

• If the head is flexed, the abdominal musculature becomes

tensed and the examination made more difficult.
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 General Considerations…

• Allowing the patient to bend their knees so that the soles

of their feet rest on the table will also relax the abdomen
• The examination room must be quiet to perform adequate
auscultation and percussion.
• Keep the room as warm as possible and make sure that
the lighting is adequate
• Watch the patient's face for signs of discomfort during
the examination.
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Draping the Abdomen

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 General Considerations…
• Use the appropriate terminology to locate your
findings:
 Right Upper Quadrant (RUQ)
 Right Lower Quadrant (RLQ)
 Left Upper Quadrant (LUQ)
 Left Lower Quadrant (LLQ)
 Midline:
 Epigastric
 Suprapubic

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4 regions

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9 regions

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Right upper quadrant which contains
– The right adrenal gland
– Part of the colon
– Duodenum
– Portion of the right kidney
– Liver
– Head of pancreas
– Pylorus and loop of small intestine
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 Right lower quadrant contains

• The appendix
• The distended bladder
• Cecum
• Lower pole of the right kidney
• The right ovary, the right uterus

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Left upper quadrant contains
• The left adrenal gland & portion of the left kidney
• Body of pancreas
• Spleen, stomach

Left lower quadrant contains

• The distended bladder
• The sigmoid and part of the descended colon
• The lower pool of the kidney
• The left ovary
 Midline below the symphysis pubis: bladder, uterus
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Topical Anatomy of the Abdomen

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Subjective data
• Ask for appetite, dysphagia, food intolerance, abdominal
pain,
• Nausea/vomiting,

• Bowel habit, and past abdominal surgery.

Objective data
Equipment needed
Examination table, drape, Stethoscope, small centimeter
ruler and skin marking (pen)
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 Technique of abdominal examination

• Position the patient supine, relax him and avoid full

bladder.
• use adequate light and proceed in the order of

1. Inspection
2. Auscultation
3. Percussion, and
4. Palpation

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 1. Inspection

• Much information can be gathered from simply

watching the patient and looking at the abdomen.
• This requires complete exposure of the region
• The shape, symmetry, umblicus, skin, pulsation of
movement and hair distribution
Contour- stand on the right side and look down on the
abdomen
 See the profile from the rib margin to the pubic bone
 The contour describes the nutritional state, and normally
ranges from flat to round.

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 Inspection….

Abdomen
• Protuberant abdomen as in pregnancy.
• Any abdominal distension(fat, fluid, faeces, fetal growth,
fibroids, flatus)
• Symmetry- normally the abdomen should be symmetric
bilaterally
• Note any localized bulging, visible mass or asymmetric
shape
• Peristalsis
• Pulsation of the aorta in the epigastric area
• vein is commonly dilated in hepatic cirrhosis or in inferior
vena cava obstruction
• Presence of surgical scars or other skin abnormalities.
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 Contour of the abdomen

PROTUBERANT SCAPHOID

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DILATED VEIN OF HEPATIC CIRRHOSIS

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 Inspection….
Umbilicus
• For contour, location, sign of inflammation or
hernia
• Normally it is midline and inverted with no
signs of inflammation or hernia
• It becomes pushed upward with pregnancy.

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UMBILICAL HERNIA IN NEWBORN

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 Clinical correlations
• Asymmetry of the abdomen can result from variety of causes
(organomegally, bowl obstruction, hernia, tumor, cysts & spinal
curvature)

• Elevation in Right Upper quadrant= liver tumor

• Asymmetry of the lower abdomen= pregnancy, bladder distention, or

mass in ovaries, uterus, or colon

• Round abdomen is normal for children < 4 years age.

• Scaphoid abdomen in child is sign of malnutrition or sever

dehydration.

• Visible peristalsis may suggest early obstruction

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 2. Auscultation

• Auscultation assess the sound of peristalsis & vascular

abnormalities
• It is performed before percussion or palpation as vigorously
touching the abdomen may disturb the intestines, perhaps
artificially altering their activity and thus bowel sounds.
(increase peristalsis).
• Use the diaphragm-end piece because bowl sounds are
relatively high pitched.
• Hold the stethoscope slightly against the skin: pushing too hard
may stimulate more bowel sounds. 21
 Auscultation…
• Listen for bowel sounds and note their frequency and
character.
• Normal sounds consist of clicks and gurgles, occurring
at an estimated frequency of 5 to 34 per minute.
• Begin in the RLQ at the ileocecal valve because bowel
sounds are always present here normally
• Do not bother to count it, judge for presence of

hypoactive or hyperactive bowel sounds.

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 Auscultation…

• Perfectly silent abdomen is uncommon you must listen

for 5 minutes before saying absent bowel sounds .

Abnormal bowel sounds

• One type of hyperactive bowel sounds which is
common in hunger or diarrhea which is
hyperparastalisis is known as “borborygmi”
• Hyperactive sounds are loud, high pitched rushing

• EX. Diarrhea, obstruction, medications such as laxative

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 Auscultation…
• Hypoactive or absent sounds following abdominal
surgery, paraliticileus or with inflammation of the
peritoneum

• Bruits in the epigastric and upper quadrants: if patient

has high blood pressure listen in the epigastrium and
upper quadrant for both systolic and diastolic bruits
which strongly suggest renal artery stenosis as the
cause of hypertension
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25
 3. Percussion

Abdominal percussion has the following purposes:

1. To assess the amount and distribution of gas in the

abdomen
2. To identify the possible masses that are solid or fluid filled
3. To estimate size of liver and spleen
4. To assess ascites

 Normally, percussion all over the four quadrants of the

abdomen provides predominantly tympanic because of gas
in the GIT
 But scattered area of dullness due to fluid and feces are also
typical 26
 Percussion….

• Tympanic through out a protuberant abdomen suggest

intestinal obstruction
• Large and dull area may indicate under lying mass or
enlarged organ
• While dullness in the flunks of a protuberant
abdomen indicates the need for assessment of ascites

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 4. Palpation

• Before performing abdominal palpation consider the

following:
 Begin with light palpation.

 Ask the patient to point you any areas of pain and examine

painful or tender area last

 Monitor your examination by watching the patient’s face or

sign of discomfort
 Approach slowly and avoid quick, unexpected movements

 Distract patient if necessary with conversation or questions.28

 Palpation….
• Abdominal palpation may be light or deep
Light palpation
 With the first four fingers close together depress the skin about
1cm
 Make a gentle rotary motion, sliding the fingers and skin together

 Then lift the fingers and move clockwise to the next location
around the abdomen
 The objective here is not to search for organs but to perform an
over all impression of the skin surface and superficial
musculature
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 Palpation….

Light palpation is used to identify:

 Abdominal tenderness
 Muscular resistance
 Superficial organ or mass

Abnormal –involuntary rigidity is a constant board like

hardness of the muscles as in peritonitis

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Light palpation

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 Palpation….
• Deep palpation
 Push down about 5-8 cm
 Moving clockwise, explore the entire abdomen
 In case of very large or obese abdomen use bimanual
technique
• Using the palmer surface of your fingers. place your two
hands on top of each other, the top hand does the pushing,
the bottom hand is relaxed and can concentrate on the
sense of palpation.
Use to identify
– Abdominal mass
– Abdominal organs
– Deep pains 32
Two-handed deep palpation

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 Assessment of the liver

• Most of the normal liver is sheltered by the rib cage and

assessing it, is difficult.
• Abnormality can be assessed using two techniques
percussion and palpation
Percussion: can be used
 To estimate size and shape of the liver
 To determine the vertical span of the liver

The vertical span of the liver can be assessed in the mid

sternal line and more commonly in the right middle
clavicular line
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 The vertical span…
• Percuss down from the area of lung resonance and
percuss down the interspaces until the sound change
dullness quality, mark the spot, usually in the right
mid-clavicular line in the 5th intercostals space.

• Then find abdominal tympany and percuss up in the

right mid clavicular line mark where the sound changes
from tympany to a dull sound, normally at the right
costal margin.
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 The vertical span…

• Measure the distance between the two marks

• The normal liver span in the adult ranges from 6-12
cm in the mid clavicular line and 4-8 cm in the mid
sternal line
• Abnormal –enlarged liver span (hepatomegaly)

EX. Heart failure and hepatitis

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4-8cm in
Mid sternal line

6- 12cm mid
clavicular line

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 Palpation of the liver
Is used to assess
 Tenderness
 Consistency
 Surface and may be shape of the liver

Procedure
• With your left hand Parallel to the right 11 th and 12th ribs
support the patient from behind
• Ask the patient to relax and press your left hand forward
• With the fingertips of your right hand palpate the patient
right abdomen lateral to the rectus muscle.

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 Palpation of the liver…

• The fingertips should be well below the lower border of the liver

dullness and press gently in and out

• Ask the patient to take deep breath. It is normal to feel the edge

of the liver strike your fingertips as the diaphragm pushes it

down during inhalation

• The normal liver is soft (may be slightly tender), sharp, regular,

and with a smooth surface

• Abnormal –liver palpated more than 1-2cm below the right costal

margin is enlarged. 39
Palpation of the liver…

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 Assessment of the spleen
• The spleen located in the curve of the diaphragm just
posterior to the left midaxillary line
• Percussion and palpations are used in the assessment of
spleen
• When a spleen enlarges, it expands anteriorly,
downward, and medially, often replacing the tympany
of stomach and colon with the dullness of a solid organ
and it becomes palpable below the costal margin.
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 Assessment of the spleen…

Percussion of spleen
 Percussion can not confirm splenic enlargement, but
can raise the suspicions. Because fluid and solids in
the colon or stomach can interfere with finding.

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 Two techniques may help you to detect
splenomegaly
1.Percussion. At the Traubs space
• Percuss the left lower anterior chest wall between
lung resonance above and the costal margin (an area
termed Traube’s space).
• If tympanic note is prominent, especially laterally,
spleenomegally is not likely
• Dullness rise the spleenomegally
• Other causes of dullness in the traubs space include
fluids or solids in the colon or stomach

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 Assessment of the spleen….
2.The splenic percussion sign
• Percuss the lowest interspaces in the left anterior
axillaries line
• Normally this area is tympanic to percussion
• Then ask the patient to take deep breath in and hold
percuss again
• When spleen size is normal Percussion note usually
remains tympanic through full inspiration.
• Change in percussion from tympany to a dull sound
with full inspiration is a positive spleen percussion sign
• Example ,Splenomegaly in malaria
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 Assessment of the spleen….
Palpation of the spleen
• Palpation can confirm enlarged spleen
• Normally the spleen is not palpable and must be enlarged
three times its normal size to be felt.
• The normal size is about 11 cm (4.3 inches) vertically in
its longest dimension
• Reach your left hand over the abdomen and behind the
left side at the 11th and 12th ribs
• Lift up for support
• Place your hand obliquely on LUQ with the fingers
pointing toward the left axilla and just inferior to the rib
margin
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 Palpation of the spleen….

• Push your hand deeply down and under the left costal
margin and ask the person to take a deep breath. You
should feel nothing firm.
• When enlarged, the spleen slides out and bumps your
fingertips.
• It can grow so large that it extends in to the lower
quadrant

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Palpation: Spleen

Palpation: Spleen
(correctly - position,
breaths, palpating
deepest full
inspiration, 1 hand
under L side, 1
feeling)
Palpation: Spleen (if
not palpable, R lateral
decubitus)
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 Palpation of the spleen….

• Repeat with the patient lying on the right side with

legs somewhat flexed at hips and knees. In this
position, gravity may bring the spleen forward and to
the right into a palpable location.

• Abnormal – if you feel an enlarged spleen, refer the

person but do not continue to palpate it. Is friable and
rupture easily with over palpation
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PALPATING THE SPLEEN-PATIENT LYING ON RIGHT SIDE

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The enlarged spleen shown below
is palpable about 2 cm below
the left costal margin on deep
inspiration

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• The following help to differentiate an enlarged spleen from
an enlarged left kidney
 Radiology

 The spleen passes the mid line of the body but the
kidney does not
 The spleen has notch

 The palpating hand can not be inserted between mass

and lower rib cage in case of spleen
 There is percussion dullness when the spleen is enlarged
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 Assessment of the kidneys
The most important technique in the assessment of the
kidney is palpation
• Kidneys are usually not palpable in adults unless quite
enlarged
• Kidneys are deep in the flank and move down with
inspiration.
To Palpate for masses :
• Use deep pressure with the palmar aspect of your
fingers, with a rolling motion.

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 Assessment of the kidneys…

• To palpate the right kidney rests your left hand at the

12 ribs and your right hand gently in the right upper
quadrant lateral and parallel to the rectus muscle.

• Ask the patient to breath deep and at the peak of

inspiration press your right hand firmly and deeply in
to the right upper quadrant just below the costal
margin and try to capture the kidney

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 Assessment of the kidneys…
• Ask the patient to breath out and then stop breathing
briefly. slowly release the pressure of your upper
hand feeling at the same time for the kidney to slide
back in to the respiratory position.
• To palpate the left kidney be on the left side of the
patient and try similarly
• The left kidney sits 1cm higher than the right kidney
and is not palpable normally.
• The right kidney is palpable more often than the
left.

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Posterior View: Location of the Kidneys

L
R

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Palpation of the Right Kidney

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 Palpation of Kidneys

Right kidney (take a deep Left kidney (take a deep breath,

breath, capture kidney, exhale, capture kidney, exhale, slowly
slowly release kidney release kidney)

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 Assessing Kidney Tenderness
Costo-vertebral angle(CVA) tenderness.
• Percussion of the kidneys helps assess pain or
tenderness.
• Assist the client to a sitting position, and stand behind
the client.
For indirect percussion
• Place the palm of your non dominant hand over the
costovertebral angle strike this area with the ulnar
surface of your dominant hand, curled into a fist

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 Assessing Kidney Tenderness..

• For direct percussion, also strike the area over the

costovertebral angle with the ulnar surface of your
dominant hand, curled into a fist. Repeat the technique for
the other kidney.
• You should do percussion of the kidneys with only
enough force so the client feels a gentle strike.
• Percussion is usually done at the end of the
assessment.

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 Assessing Kidney Tenderness…

12th rib

Costovertebral angle
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 The Bladder

• The bladder normally cannot be examined unless it is

distended above the symphysis pubis.
• On palpation, the dome of the distended bladder feels smooth
and round. Check for tenderness.
• An empty bladder is not palpable
• Bladder percussion is unnecessary unless there is a suspicion
of urinary retention
• Use percussion to check for dullness and to determine how
high the bladder rises above the symphysis pubis.
Abnormal
• Bladder distention from outlet indicates obstruction due to
urethral stricture, prostatic hyperplasia
• Suprapubic tenderness in bladder infection
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 Assessment of peritoneal irritation

• Abdominal pain ,tenderness and involuntary

muscular spasm suggest inflammation of the
peritoneum.
• Assessment can be done in a systematic manner
• First ask the patient to cough and determine where
the cough produce pain
• Guided by the pain produced by the cough palpate
gently with one finger to map the tender area
• If this gently maneuvers cannot produce any area of
the peritoneal inflammation look for rebound
tenderness.
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 Assessment of peritoneal irritation…

• To do this
– Press your finger in firmly and slowly and then
withdraw quickly
– Then ask the patient to show you exact where it
hurt and to compare which hurts more the pressing
or the letting down
– Pain induced or increased by quick withdrawal
constitute rebound tenderness

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Assessment of possible ascites

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 Assessment of possible ascites

• Protuberant abdomen with bulged flunks is an

indication for assessment of possible ascites.
• Because ascitic fluid characteristically sinks with
gravity, while gas-filled loops of bowel float to the
top
you can do this in three ways and you better combine
with

1.Check the presence of tympany at top and dullness at

the periphery

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Tympany at top and dullness at the periphery

tympany

dullness

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 Assessment of possible ascites…

2.Check for shifting dullness

– Map boarder of tympany and dullness by
purcession
– Ask the patient to turn on to one side
– Percuss and map the borders again
– Dullness shifting to the more dependent side
suggest ascites

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 Assessment of possible ascites…
3.Test for fluid wave (fluid trill)
– Ask some one (it may be the patient )to press the
edge of his hands against the middle of the
abdomen (this stop the transmission of the pressure
through fat ) and tap one flunk sharply with your
fingers
– Feel the impulse transmitted through the fluid on
the opposite flank with your opposite hand
– An easily palpable impulse suggest ascites

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Assessing for a fluid wave

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 Assessment of possible appendicitis

1.Rove sings and rebound tenderness

• Press deeply and evenly in the left lower quadrant
and quick withdraw your fingers
• Pain in the lower right qudrant during left sided
pressure is termed positive Rovsings sign and
suggests appendicitis.
• Rebound tenderness is when the examiner presses on
a part of the abdomen and the patient feels more
tenderness when the pressure is released than when it
is applied
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 Assessment of possible appendicitis…
2. Psoas sign
 With the person supine ,lift the right leg straight up,
flexing at the hip;
 Then push down over the lower part of the right thigh
as the person tries to hold the leg up
 When the test is negative, the person feels no change
 Increased abdominal pain on this maneuver
constitutes a positive psoas sign, suggesting irritation
of the psoas muscle by an inflamed appendix

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 Assessment of possible appendicitis…
3. Obturator sign
• With the person supine, lift the right leg, flexing at
the hip and 90 degrees at the knee.
• Hold the ankle, and rotate the leg internally and
externally. This stretches the internal obturator
muscle
• Normal response is no pain
• Right hypo gastric pain positive obturator sign
suggest appendicitis

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 Assessment of hernia in the groin

• The techniques used are inspection, palpation

and some times auscultation for bowel sound
Inspection
• Note any bulges
• Ask the patient to strain down. a bulge that
appears or increase on straining suggests a hernia

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 Assessment of hernia…
• Inspect & palpate the abdomen for the presence of
hernias.
• The three most common types of hernias are ventral,
umbilical & inguinal.
• Ventral hernia occur at weak points on the
abdomen(eg. incisional hernia)
• It usually appears as soft mass on the abdominal
walls(seen & palpated)
• Coughing generally causes it to bulge outward.

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 Assessment of hernia …
Palpation
• Note any palpable herniating mass while the
patient is straining or cough.
• To palpate for a femoral hernia place your finger
on the femoral canal and ask the patient to strain.
• Note any swelling or tenderness.

Auscultation
• Audible peristaltic movement indicate hernia
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 Assessment of hernia …
• Umbilical hernias are most congenital & best
visualized when the client coughs.
• When you push your index finger in to the navel, a
ring of fascia will be detected around a soft center.
• It may occur with pregnancy, ascites, & obesity.

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Umbilical Hernia

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