Abdominal Exam

Required Prep: Bates’ Text: Ch. 11 - The Abdomen

Bates’s PE videos: Vol. 13, or JoVE videos – Abd exam I-IV (https://www-jove-
com.proxy.cc.uic.edu/education/20/physical-examinations-ii) that are more detailed
Abd draping - https://www.youtube.com/watch?v=6aMU4IN2aGw,

Goals:
1. Practice the abdominal exam
I. Agenda

A. Students will perform the Abdominal exam on each other

B. Practice appropriate draping techniques
C. Preceptors will clarify and demonstrate exam techniques, as needed
D. Review abdominal and inguinal lymph node drainage
E. Discuss appropriate documentation and ROS of the abdominal exam
F. Discuss clinical applications (Part V)

II. Abdominal
A. Order of exam
1. Appropriately drape the Pt
2. Inspection
3. Auscultation
4. Percussion
5. Palpation
6. Special Tests
B. Inspection of the abdomen
1. Abdominal wall and flanks
2. Shape
3. Identifying marks
The abdominal contour is described by its profile while the patient is lying flat, but it is also good practice to view
the Pt’s abdomen from the foot of the bed to see other subtle contours. Normal contour depends on the body
habitus. Thin individuals have a concave profile that is described as scaphoid. In others the contour is flat. Obese
patients have a protuberant contour. Protuberance can also be caused by gas or fluid (ascites). Abdominal
distention is protuberance secondary to something like gas or ascites. Other abnormal findings to look for include
visible defects in the muscular wall, visible pulsations, scars, rashes, and stigmata of liver disease.
C. Auscultation of the Abdomen

It is best to listen to the abdomen prior to palpation as palpation may alter the bowel sounds. High-
pitched bowel sounds, rushes, tinkling, or the absence of bowel sounds should be documented. Bruits
should also be documented.

1. Listen for bowel sounds

 Traditionally it was taught you always needed to listen in all four quadrants, and this is still true if
you have not been able to appreciate any bowel sounds. However, if you hear bowel sounds in one
location, it is not necessary to listen in other locations since the sounds resonate throughout the
abdominal cavity.
 Bowel sounds have little value in the routine abd exam when Pt’s are not presenting with an abd
concern and are strongly related to when the Pt last ate.

1
  Sounds are more important to assess in Pt’s presenting with abd pain and post-operatively
2. Listen for bruits over aorta, renal, and iliac arteries when clinically
indicated
 Please note the location of the kidneys along the transpyloric
plane, which is located at the level of L1, posteriorly, and at the
9th costal cartilage, anteriorly
 Also note the location of the kidneys at the transpyloric plane in
comparison to the umbilicus
 Many videos incorrectly show auscultation of the renal arteries
near the umbilicus, which would only be appropriate if your Pt
had a short torso and their umbilicus was located at the level of
the 10th rib. Be sure to assess the surface anatomy of your Pt
before you auscultate for arterial bruits.

D. Percussion of the Abdomen

You should percuss the abd with the expectation of hearing tympani from the air in the bowel. When you hear
dullness, note each area and investigate it more thoroughly during palpation. Frequently, dullness is from stool, but
it could be a mass, organomegaly, or from ascites.

Percussion may be your first clue to discover tenderness. If a Pt has tenderness to percussion, expect them to have
even more tenderness to palpation.

1. Percuss all four quadrants, the epigastric area and the suprapubic area, and note the quality of
the percussion note (tympanic, resonant, dull).

2. Percuss the liver span at MCL

Be sure the Pt’s arms are down at their sides and their legs are bent with their feet on the table. Start in
the chest and work your way down to find the upper margin, and start in the RLQ and work your
way up to find the lower edge.
 Clinicians tend to underestimate the liver span, and hard percussion increases this
underestimation—percuss softer than usual.
 Percussion is the method to determine if the liver is enlarged…not palpation.

3. Castell’s sign - Percuss for splenomegaly in the ninth, left intercostal space along the anterior axillary line.
First percuss and note the tone in expiration, which should be resonant, and then percuss after the Pt
inhales and holds their breath, which again should be resonant. Inhalation causes the spleen to descend,
and if enlarged it will cover this area and make it dull. (Positive if dull during inhalation and resonant
after exhalation)

4. Percuss for Costovertebral angle tenderness – You may decide to do this prior to the Pt lying down, or
after the Pt sits up at the end of your abd exam. Find the CVA and place hand flat on the CVA
and
strike with opposite fist (don’t use fist directly on skin). Recall that the kidneys are usually located
between T12 and L3 and our partially covered by the 11th and 12th ribs, with the right being a little
lower than the left due to the liver. (Demonstrated in Bates’ video 13.3)

2
 5. Suspected ascites
 Pt’s with known liver disease, Pt’s suspected of liver disease, or Pt’s with abdominal
protuberance and lower extremity edema should all be assessed for ascites
a. Bulging flanks is very sensitive but not at all specific because it has many causes
b. Shifting dullness assessment – First, percuss in the flanks and if dull then percuss toward the midline
until tympani is heard. Perform this more than once to establish a transition line from dullness to
tympani that may indicate an air-fluid level. Then ask the Pt to turn to that side and again percuss
from the flank toward the midline to establish an air-fluid level. If the fluid level has shifted with
gravity as the Pt changed positions, then shifting dullness is said to be positive. Air rises and
fluid falls.
c. Fluid wave – First, ask the Pt or another examiner to press their hand into the midline of the abdomen
which will prevent the vibrations from being transmitted through the abdominal wall. Next, place
one hand on each side of the abdomen. Use fingers of one hand to gently strike the side of the
abdomen while the other hand feels on the other side. If significant ascites is present within the
abd cavity, you may be able to generate a wave from the strike of your fingers that is transmitted
to the other side and felt by your other hand, which would be a positive fluid wave.
E. Light Palpation of the Abdomen—Feeling for possible abnormalities in the abdominal wall. Starting away from
the location of pain, place your entire hand and fingers on the abdominal wall and then use your fingers
to feel the superficial structures
1. Palpate all areas of the abdomen (Epigastric area, suprapubic area, and 4 quadrants)
a. Identify areas of superficial tenderness
b. Identify abd wall and superficial masses
c. Check for guarding and rigidity
d. Check for flank tenderness
F. Deep Palpation – Feeling for possible abnormalities within or deep to the abdominal cavity. Having the patient’s
arms at sides and knees bent will help relax the abdominal muscles and facilitate the exam.
Palpate all areas of the abdomen using a flat hand (Epigastric area, suprapubic area, and 4
quadrants). If your Pt has abd pain, be sure to start your palpation away from the area of pain
and palpate it last. Note: If the Pt’s abdomen was tender to percussion or light palpation, it’s
going to be even worse with deep palpation (no need to torture your patient)

1. Identify masses
2. Estimate size of the aorta (See CV handout) and abdominal organs (see below)
3. Assess tenderness
4. Evaluate for rebound tenderness

G. Palpation of liver
By percussing the liver size first, you will have a good idea where the liver is located.
a. Span
 Palpation of the liver starts in the RLQ (at least a few cm below the edge you found with
percussion). Use your left hand to pull the liver anteriorly from behind, and use your right
hand for liver palpation. Using light to medium palpation, ask the Pt to take deep breaths that
will push the liver downward with each inspiration. With each inspiration, try to feel the
liver tap your hand or run under your fingers. If not found, move up a cm with each breath
until the liver edge taps your hand or runs under your fingers. Once located, feel along the
liver edge to note its consistency and assess for tenderness.
 A palpable liver edge is not a reliable sign of liver enlargement, but suggests further exam
needs to be done to determine if the liver is indeed enlarged. Recall that the normal liver
edge is anatomically located 1-3 cm below the costal margin. If you think you felt the liver,
the odds are high you are correct (LR 233).
b. Tenderness
3
  Usually non-tender, except for acute hepatitis or cholecystitis
c. Consistency
 Smooth vs. Nodular – Once you find the liver, slide your fingers along the inferior border to
assess its consistency.

H. Palpation of spleen
 The spleen enlarges toward the RLQ – follow same steps as the liver exam by pulling the spleen
anteriorly with your left hand and using your right hand to palpate as you gradually move your hand
up toward the LUQ

I. Palpation of kidneys – Place one hand on the costovertebral angle to lift anteriorly, and then palpate
deeply with the other hand to try to feel the kidney between your hands or with your top hand. Recall
location of kidneys from the image above.

J. Write in the meaning of these Signs and Special Tests and when each is clinically indicated
1. Peritoneal signs – signs of possible peritonitis that may signify an acute abdomen needing emergent
surgery
a. Involuntary Guarding
b. Rebound tenderness
c. Percussion tenderness
d. Cough test; jarring movements
e. Rigidity
2. Murphy’s sign
3. McBurney’s point
4. Rovsing sign
5. Psoas sign
6. Carnett sign (Abdominal wall tenderness test) – locate the area of maximal tenderness
and apply additional pressure to elicit moderate tenderness. Have the Pt cross their arms across their
chest and ask them to lift their head and shoulders up off the table like an abdominal crunch. If this
causes increased pain, the test is positive signifying abdominal wall pain and not intra-abdominal pain.
When positive, this sign has a likelihood ratio of 0.1 for peritonitis, meaning peritonitis is highly
unlikely. (McGee, Evidenced-based physical diagnosis, 4th ed.)

K. ROS – It is frequently necessary to ask about systems outside of the abdomen that can generate a referred
cause of abd pain

GI: Change in appetite, abdominal pain, nausea, vomiting, change in bowel habits (frequency,
consistency, caliber, constipation, diarrhea), melena, hematochezia, clay-colored stools, recent
antibiotics, heartburn, h/o gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD),
hepatitis, gall bladder disease, difficulty/pain with swallowing, indigestion, bloating, increased
belching, hematemesis, jaundice, food intolerance, frequency of bowel movements, mucus,
excessive belching or passing of gas, incontinence, hemorrhoids, rectal itching/burning, rectal
discharge/pain, laxative use.

Urinary: Frequency of urination, dysuria, hematuria, change in color of urine, past infections, polyuria,
nocturia, flank/suprapubic pain, retention, urgency, hesitancy, incontinence, change in force of
stream, dribbling, passage of air/stone, enuresis.

4
 L. Sample write up
(It may be helpful to draw a silhouette of an abdomen to document findings such as masses, scars, or abdominal
defects.)

The abdomen was flat (scaphoid, rotund, distended, morbidly obese; describe asymmetry, deformities, scars,
hernia, striae, dilated veins, diastasis recti). Bowel sounds were present and were appropriate (absent,
increased, decreased, high-pitched tinkling, with rushes). No bruits were heard over the abdominal aorta,
renal, iliac, or femoral arteries (describe bruit). Percussion revealed normal tympany over the stomach and
gas-filled bowel (dullness or distention). The liver was ____cm at the MCL. Castell’s sign was negative
(positive). The abdomen was soft and non-tender to light and deep palpation and without guarding or
rebound (describe tenderness to light and deep palpation, location, radiation, presence of rebound, guarding,
rigidity, Murphy, McBurney, Psoas, or Carnett signs), mass (if palpated describe location, size, consistency,
etc...), or hepatosplenomegaly. The liver was palpated ___cm below the costal margin, smooth and
nontender (report tenderness, describe its consistency and report nodularity). The spleen was not palpable (the
spleen was palpable ___ cm below the left costal margin; report tenderness). The abdominal aorta measured
approximately ____ cm. There was no shifting dullness or fluid wave appreciated. No costovertebral angle
tenderness was elicited.

III. Clinical Applications

1. Discuss common locations of acute abd pain by quadrant
2. Understand the applications of the signs in II. I., above
2. Abd organ enlargement and ascites may be noted simply by inspection.
3. The return of bowel sounds after an ileus or surgery is a positive step toward recovery, and two of the most
important times to assess for bowel sounds.
4. Focal tenderness suggests organ inflammation (appendicitis, pancreatitis, cholecystitis), organ damage (stomach
ulcer), and/or secondary peritonitis.
5. Masses—the abd should be soft all over, thus firm areas may be stool, enlarged organs, or a tumor.
6. Thyroid disorders are extremely common—discuss common symptoms and signs of hypo and hyperthyroidism
7. Over 95% of thyroid nodules are benign
8. Probability of a goiter or thyroid nodule having cancer is increased in the presence of vocal cord paralysis,
cervical adenopathy, or fixation to surrounding tissues
9. Peripheral lymphadenopathy is frequently benign in the outpatient setting, but you must consider the clinical
context of the patient’s presentation
10. In Pt’s with fever of unknown cause or unexplained weight loss a detailed lymphatic exam is required.

IV. Additional Aids

A. Stanford 25 Liver, Spleen, Ascites and Rectal exams
(http://stanfordmedicine25.stanford.edu/the25/)
B. Cope’s Early Diagnosis of the Acute Abdomen (In Library, great book for all types of abd pain and determining
the cause)
C. Symptom to Diagnosis, An Evidence-based guide, 3rd Ed. – Chapter 3 Abd Pain. (e-book through your library)

5
V. Checklist for Skills verification and OSCE’s

Performed Performed Not

Abdomen Satisfactorily Incorrectly or Done
with assistance
1. Washes hands
2. Appropriately drapes the Patient
3. Inspects and describes: Abdominal wall and flanks for
contour, masses, identifying marks and movements
4. Auscultates:
a. Prior to palpation or percussion
b. Describes bowel sounds
5. Percusses:
a. All four quadrants, gastric bubble, and above
symphysis for bladder distention
b. Liver along right mid-clavicular line to determine
liver span. Normal span at right mid-clavicular line is
6-12 cm
c. Castell’s sign for Splenomegaly - In the 9th intercostal
space along the left anterior axillary line, first
percusses in full expiration and then in full
inspiration.
d. For shifting dullness
e. For fluid wave
f. Costovertebral angles (CVA) for tenderness
6. Palpates:
a. Lightly in all four quadrants, epigastric and suprapubic
areas for tenderness, mass, guarding or rigidity
b. Deeply for tenderness and masses; may assess
rebound
b. Liver - for enlargement, tenderness, consistency
c. Spleen - using bimanual technique
d. Kidneys - using bimanual technique
e. Inguinal areas
f. Aorta - estimates size
7. Describes and/or demonstrates:
a. Peritoneal signs
1. Guarding
2. Percussion tenderness
3. Rebound
4. Rigidity
b. McBurney’s point
c. Psoas sign
d. Rovsing sign
e. Murphy’s sign
f. Carnett sign
Washes hands at end of exam