Abnormal
General inspection; vital signs;
Supine Position: inspect abdomen
 skin: scars, skin abnormalities
 contour, symmetry, visible masses
 umbilicus
 peristalsis
 presence of aortic pulsations.
2. Auscultates bowel sounds (before palpating or percussion) in all quadrants.
Normal
3. Auscultates with the
bell of the stethoscope for
vascular sounds.
 Pink–purple striae are a
hallmark of Cushing
syndrome.
 Bulging flanks of ascites,
suprapubic bulge, large
liver or spleen, tumors
 Hernia, inflammation
 Increased peristaltic waves
of intestinal obstruction.
 Increased pulsations of an
abdominal aortic
aneurysm
Absent, hypoactive,
hyperactive bowel sounds
Altered bowel sounds are
common in diarrhea, intestinal
obstruction, paralytic ileus, and
peritonitis.
1. Auscultate for bruits over
the aorta, the iliac arteries, and
the femoral arteries
 Bruit of renal artery
stenosis
2. Auscultate over the liver and
spleen for friction rubs.
 Skin color uniform
 No striae, scar, lesion
present
 Contour flat or rounded
and symmetrical
 No visible masses, no
bulging
 Umbilicus no
inflammation, inverted
 Thin patients may have
visible peristalsis and
aortic pulsations
Active bowel sounds heard
in all 4 quadrants
(high-pitched clicking and
gurgling sounds
approximately every 5 to 15
seconds)
No bruits and friction rubs
  Liver tumor, splenic
infarct

4. Auscultates around the umbilicus for a venous hum.

5. Percusses in all quadrants. A protuberant abdomen that is Predominantly tympany
 Tympany- high pitched musical sound, hollow space filled by air or gas tympanitic throughout Tympany heard over air-filled
 Dullness- fluid or underlying organs like liver or spleen suggests intestinal obstruction areas such as stomach or
or paralytic ileus. intenstine

Dull areas characterize a Dullness heard over solid

pregnant uterus, an ovarian areas such as spleen, liver
tumor, a distended bladder, or or distended bladder
a large liver or spleen.
No tenderness

6. Percusses for shifting dullness (To perform both for ICA purpose). For possible ascites. Ascitic fluid characteristically
sinks with gravity, whereas
gas-filled loops of bowel rise,
dullness appears in the
dependent areas of the
abdomen.

Ascitic fluid usually shifts to

dependent side, changing the
margin of dullness
6. Percusses for fluid thrill (To perform both for A palpable wave suggests but
ICA purpose). For possible ascites. does not prove ascites.
- Tap one flank sharply with your fingertips
- Feel on the opposite flank for impulse If the distention is due to air
transmitted through the fat you will not feel any wave

7. Percusses the liver & measures liver span. Span of liver dullness is Liver span is 6-12 cm in the
a) Locate the right increased when the liver is right midclavicular line
midclavicular line. enlarged.
Start at level below
the umbilicus, in Span of liver dullness is
the right lower decreased when the liver is
quadrant, area of small, or when there is free air
tympany below the diaphragm, as from
b) then percuss up a perforated bowel
toward the liver,
identify the lower
border of dullness
in the midclavicular
line
c) Identify the upper
border of the liver
dullness. Starting at nipple line, from lung resonanance down toward liver
dullness
8. Palpates liver (if appropriate). Firmness or hardness of the Liver not palpable
liver, bluntness or rounding of
its edge, and surface or
- Place your left hand behind the irregularity are suspicious for
lower thorax liver disease. Liver edge is soft, sharp, and
- Lift up the 11th and 12th ribs regular with a smooth
overlying soft tissue surface
- Place right hand just below the
right upper quadrant
- Press gently into abdomen and
ask patient to deep breathe
- Try to feel liver edge. Note
any tenderness

Hooking technique (obese):

- stand right to patient’s chest,
place fingers of both hands
below the border of liver
dullness
- press in and up toward the
coastal margin
- ask patient to deep breathe

Assess for tenderness when liver

not palpable
- Place your left hand flat on
the right lower rib care
- Gently strike it with your
right fist
- Ask patient to compare
sensation to the other side

Tenderness over the liver

 suggests inflammation, found No tenderness over liver
in hepatitis, or congestion from
heart failure.

9. Percusses the spleen:.

When spleen enlarges, expands anteriorly downwards, replaces tympany of stomach and
colon with dullness of solid organ.

a) left lower anterior chest wall

If tympany is prominent,
especially laterally,
splenomegaly is unlikely

- Percuss the left lower anterior chest wall roughly from the border of cardiac Spleen size is normal, the
dullness at the 6th rib to the anterior axillary line and down to the coastal margin percussion note usually
(traube space) remains tympanitic
- As you percuss along the routes marked by the arrows, note the lateral extent of
tympany.

b) Splenic sign
 - Percuss the lowest interspace in the left anterior axillary line (Fig. 11-22). This
area is usually tympanitic.
- Then ask the patient to take a deep breath, and percuss again.
A change in percussion note
from tympany to dullness on
inspiration is a positive splenic
percussion sign, but this sign
is only moderately useful for
detecting splenomegaly

Palpate spleen:

- Support the left posterior rib cage

- Place right hand below the left
coastal margin
- Press in with your fingers toward Splenomegaly is eight times
the spleen more likely when the spleen is Spleen not palpable
- Repeat with patient taking a deep palpable
breath, try to feel the spleen
- Alternatively, ask patient to turn
onto the right side, with legs
somewhat flexed at hips

10. Lightly palpates all quadrants of the abdomen using pads of fingers Guarding is a voluntary
- identify any tenderness or increase resistance to your hands contraction of the abdominal
wall, often accompanied by a
grimace that may diminish
when the patient is distracted.
Soft and nontender;
No signs of guarding,
rebound tenderness, rigidity

Rebound tenderness: pain is

greater when you withdraw
your hand than when you
press down.

Rigidity is an involuntary reflex

contraction of the abdominal
 wall from peritoneal
inflammation that persists over
several examinations.

11. Deeply palpates all quadrants of the abdomen using one or two hands. Signs of Peritonitis: No palpable masses
- identify any masses; note their location, size, shape, consistency, tenderness, guarding, rigidity, and rebound
pulsations, and any mobility with respiration or pressure from the examining hand tenderness.

12. Palpates/ captures kidney (if appropriate). A left flank mass can represent Kidney not palpable
either splenomegaly or an
Left kidney: enlarged left kidney. Normal right kidney may be
- move to the patient’s left and palpable, especially when
place right hand behind the the patient is thin and the
patient, just below and parallel to abdominal muscles are
the right 12th rib with your relaxed
fingertips
- Lift, try to displace the kidney
anteriorly
- Place your left hand gently in
the left upper quadrant, lateral
and parallel to the rectus muscle
- Ask patient to deep breathe, at
the peak of inspiration, press
deeply into the left upper
quadrant just below the coastal
margin, try to capture the kidney between your hands
- Ask the patient to breathe out, then stop breathing, slowly release the pressure of your
left hand, feeling for the kidney to slide back into its expiratory position

If the kidney is palpable, describe its size, contour, and any tenderness.

13. Palpates the aorta and measures. A periumbilical or upper

abdominal mass with
- Ask patient to slowly take a deep expansile pulsations that is ≥3
breath and let out cm in diameter suggests an
 - Press upper abdomen slightly left of midline and feel for aorta pulsations AAA

- Try to assess width of aorta Normally, less than 3cm

(esp in older smokers at risk for
abdominal aortic aneurysm)
- Press gently on each side of
the aorta, try to estimate width

14. Palpates inguinal lymph nodes.

Sitting up Tender in pyelonephritis Normal: no costovertebral
15. Assesses costovertebral angle for tenderness. angle tenderness

- Place the ball of one hand in the CVA and strike it with the ulnar
surface of your fist