Abdomen

Objectives:
The objectives for mastering the abdomen examination are:
a. To inspect for symmetry, scars and striae
b. To auscultate bowel sounds
c. To percuss the liver and measure its span
d. To perform light and deep palpation of the abdomen and palpate the liver edge
e. To examine the spleen and assess costovertebral angle tenderness

Anatomy Review:
Abdominal wall extends from the:
a. Ribcage – superiorly
b. Pelvis, Inguinal ligaments – inferiorly
Divisions of the abdomen:

Abdominal cavity extends

up under the ribcage to the
dome of the diaphragm
 - Components:
a. Liver (most)
b. Stomach (most)
c. Spleen – posterior to the left midaxillary line
Abdominal aorta – palpable in the upper abdomen; bifurcates into the common iliac arteries below the
umbilicus; becomes the femoral arteries when the external iliac arteries pass under the inguinal
ligaments.
Intestines – fill much the abdomen; sigmoid, portions of the transverse and descending colon are
palpable as tubular structures
Kidneys – posterior; partly protected by the posterior ribs; locate the costovertebral angles to assess for
kidney tenderness.

Examining the abdomen:

1. Make sure that the patient has emptied his bladder, before the examination.
2. Inspect the skin for:
a. Scars
b. Striae
c. Dilated veins
d. Rashes
e. Ecchymoses
f. Symmetry and contour of the abdomen
(1) Flat
(2) Rounded
(3) Protuberant
(4) Markedly concave
(5) Hollowed
(6) Presence or absence of bulges
g. Contour of the umbilicus
h. Peristaltic or aortic pulsations in the epigastrium
3. Listen for/ over:
a. bowel sounds
b. iliac arteries
c. femoral arteries
4. Percuss the abdomen to assess the distribution of tympany and dullness.
5. Palpate:
a. Four quadrants (gently)
b. Four quadrants (pressing more deeply)

Examining the liver:

1. Percuss the span of the liver, done by:
a. Locating the midclavicular line
b. Start at the level below the umbilicus in the RLQ, in an area of tympany, percuss up toward
the liver. Identify the lower border of dullness in the MCL
 c. Identify the upper border of liver dullness. Starting at the nipple line, lightly percuss from
lung resonance down toward liver dullness. Measure the span of liver dullness between
those two points.
2. Palpate the liver by:
a. Placing your left hand behind the lower thorax, lifting the 11 th and 12th ribs overlying soft
tissues.
b. Place your right hand just below the right upper quadrant lateral to the rectus abdominus
muscles and well below the lower border of liver dullness.
c. Let the patient breathe deeply.
d. Press gently into the abdomen and, as the patient breathes in deeply, try to feel for the liver
edge as it moves down to meet your fingertips.
e. Standing to the right of the patient’s chest, place the fingers of both hands below the border
of liver dullness and press in and up toward the costal margin.
f. Ask the patient to take another deep breath.
g. To assess for tenderness when the liver is not palpable, place your left hand flat on the right
lower rib cage and gently strike it with the ulnar surface of your right fist.
h. Ask the patient to compare the sensation.

Examining the spleen:

1. To palpate the spleen to assess its size:
a. Reach over and around the patient with your left hand to support the left lower posterior rib
cage and overlying structures.
b. Place your right hand below the left costal margin and press in with your fingers toward the
spleen. Let the patient take another deep breath.
c. When the patient takes a deep breath, try to feel the spleen as it comes down to meet your
fingertips.
d. Alternatively, ask the patient to turn onto the right side, with the legs somewhat flexed at
the hips. In that position, gravity may bring the spleen forward and to the right into a
palpable location
2. Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th
rib to the anterior axillary line and down to the costal margin (Traube’s space)

Examining the kidneys:

1. Palpation of the left kidney:
a. Move to the patient’s left side and place your right hand behind the patient.
b. Just below and parallel to the right 12th rib with your fingertips just reaching the
costovertebral angle. Lift trying to displace the kidney anteriorly.
c. Place your left hand gently in the left upper quadrant, lateral and parallel to the rectus
muscle.
d. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly
and deeply into the left upper quadrant, just below the costal margin and try to capture the
kidney between your hands.
e. Ask the patient to breathe out and then stop breathing.
 f. Slowly release the pressure of your left hand feeling at the same time for the kidney to slide
back into its expiratory position.
g. If the kidney is palpable, assess its size, contour, and any tenderness.
2. Palpation of the right kidney:
a. Return to the patient’s right side and use your left hand to lift up from the back and your
right hand to feel deep in the right upper quadrant. Proceed as before.
3. To assess the aorta:
a. Press the upper abdomen slightly left of midline and feel for the aorta’s pulsations.
b. Assess the width of the aorta by pressing gently with a hand on each side of the aorta, try to
estimate its width.
4. To assess for costovertebral angle tenderness (or CVAT):
a. Place the ball of your left hand on each costovertebral angle in turn and strike it with the
ulnar surface of your fist.

Special techniques:
1. To assess for a fluid wave:
a. Tap one flank sharply with your fingertips while you feel on the opposite flank for an
impulse transmitted through the fat.
2. To assess for possible appendicitis:
a. Search carefully for an area of local tenderness (McBurney’s point), which lies two
centimeters from the ASIS on a line drawn down from the umbilicus.