[MED201] CLINICAL MEDICINE

ABDOMEN RETURN DEMO SCRIPT

[Wash hands, introduce yourself, and check patient’s ID. SECURE CONSENT.]

“Good evening. I am Dr. _____. May I know your name? I will be examining your
abdomen today, is that alright with you? Please let me know if you feel uncomfortable at
any moment.”

[Position patient - supine. Hands of the patient on the sides. Pillows can be placed
under patient’s head and flexed knees. Drape and adequately expose abdomen
(subcostal margin → symphysis pubis). Position yourself on the right side of the patient.
Your fingers should be short.]

I. INSPECTION

1. Measure abdominal circumference

○ Use measuring tape
○ At level of umbilicus
○ “It is ___ cm at the level of the umbilicus.”
○ Make sure it’s exact measurement
2. Abdominal contour
○ Checking for shape
○ Look tangentially
○ Draw imaginary line from xiphoid → symphysis pubis
■ If it goes beyond the imaginary line, then it is a globular abdomen.
■ If below the line, then it is scaphoid abdomen.

■
○ “Abdomen is flat.”
3. Check symmetry/localized bulging
○ “Abdomen is symmetrical with no localized abnormal bulgings.”
4. Check skin
○ Color, Disoloration, Lesions, Superficial Veins
○ E.g. Operative scars from appendectomy
○ Check striae, subcutaneous blood vessels, hematoma
○ “Skin is brown in color. There are no discoloration, lesions, or superficial
veins. There are also no striae, scarring, or hematoma.”
5. Describe Umbilicus
seen.
No vascularities ha n re. ♡

vasculitis -> postal t

[MED201] CLINICAL MEDICINE

○ Flat/Everted/Inverted?
○ Check for any nodules in periumbilical area
○ “Umbilicus is inverted.”
○ “No signs of infections. No discharge. No stones.”
6. Abdominal Movements
○ Check for visible pulsations or peristalsis
○ “There are no visible pulsations or peristalsis.”

II. AUSCULTATION [Auscultate before P/P for unadulterated bowel sounds]

1. Bowel Sounds & Borbrygmi

3
○ Warm the stethoscope and use diaphragm
○ RLQ → RUQ → LUQ →LLQ -
30
○ Listen for bowel sounds first at RLQ
○ Count the number of bowel sounds for a FULL MINUTE
■ <5 bs/min: hypoactive
■ >35 bs/min: hyperactive
Bowl
○ Note intensity
○ “Bowel sounds are 26 cycles per minute.”
sands
& uebe
2. Bruits -

○ Epigastric area - abdominal aorta bruits

■ E.g. Abdominal aortic aneurysm
○ R&L UQ - right & left renal arteries bruits
■ E.g. Renal stenosis → use bell
○ R&L LQ - iliac arteries bruits
○ “No bruits heard over the epigastric, right and left upper quadrants, and
right and left lower quadrants.”
3. Abdominal Friction Rub over RUQ&LUQ
○ Heard if there are clinical findings; inflammation/infarction/infection
○ Sound of leather rubbing/grating

ha n re. ♡
[MED201] CLINICAL MEDICINE

III. PALPATION

[Stay on right side of the patient. Position patient correctly. Ask patient if there is
abdominal pain. If patient directs to the area of pain, palpate the area of pain last.]

A. LIGHT PALPATION

1. Technique
○ One hand
○ Fingertips sunk in the abdomen around 1 cm
○ Observe patient’s expression to see if there is any discomfort
2. Asses Tenderness, Palpable Mass
○ “There are no superficial tenderness or masses.”

B. DEEP PALPATION

1. Technique
i. Single Hand Palpation
○ Similar to light palpation but around 4-5 cm
○ Make sure to reach all sides
ii. Reinforced/Double-Handed Palpation
○ Both hands (fingers) piled on top of each other for more intensity
■ Hand below is for feeling
■ Hand above is to apply pressure
iii. Bimanual Palpation

ha n re. ♡
[MED201] CLINICAL MEDICINE

○ RUQs

■
■ Push the hand in during expiration after a deep breath
○ LUQ

■
■ Bring hands closer during inspiration to feel
2. Assess Tenderness, Palpable Mass
○ “Abdomen is soft, non-tender, no organomegaly, and no masses noted.”

C. PALPATION OF LIVER

1. Technique
i. One hand
○ Start below umbilicus
○ Go up (direction of head) to feel the edge of the liver
ii. Hooking technique
○ Usually skipped because it will hurt the patient
○ Only done when necessary
○ Position still at right side but near the head, facing the feet

ha n re. ♡
[MED201] CLINICAL MEDICINE

○
2. Findings if palpable:
○ How many fingerbreadths below RSCM? 3 fingers.
○ Character of liver edge
○ Is the edge sharp? Is the surface coarse? Is it nodular?
○ Consistency
○ Tenderness
○ “Liver is not palpable. No hepatomegaly.”
○ “Liver is firm, with smooth edges, no hepatomegaly.”

D. PALPATION OF SPLEEN

1. Technique
○ Patient on supine
○ LUQ
○ Bimanual palpation

■
○ Repeat palpation with patient lying on their right side with hips and knees
flexed

ha n re. ♡
[MED201] CLINICAL MEDICINE

○ Hooking technique (middleton’s method) ONLY DONE WITH EXAMINER

ON LEFT SIDE OF THE PATIENT
2. Findings on palpation
○ How many fingerbreadths below LSCM?
○ Character of liver edge
○ Consistency
○ Tenderness
○ “Spleen is not palpable. No splenomegaly.”

E. PALPATION OF KIDNEYS

1. Technique
○ Patient on supine
○ Bimanual palpation

■
○ Ask the patient to take a deep breath and press your fingers at the height
of inspiration
○ Try to feel the border of the kidney
○ Do it BOTH sides
○ Left Kidney → do bimanual palpation from right side of patient, then move
to the left side of patient to do capture technique
2. Findings on palpation of Right Kidney
○ “Right kidney is not palpable.”
3. Findings on palpation of Left Kidney
○ “Left kidney is not palpable.”

F. PALPATION OF ABDOMINAL AORTA

1. Technique
○ Deep Palpation
○ Reinforced Palpation
○ Bimanual Palpation
○ Palpate ABOVE umbilicus

ha n re. ♡
[MED201] CLINICAL MEDICINE

○
○ Only thumb is needed in thin individuals
2. Findings
○ Width of abdominal aorta
■ “Abdominal aorta is 2.5 cm wide. Aortic pulsation is anterior in
direction.”
○ Direction of aortic pulsation

IV. PERCUSSION

A. GENERAL TYMPANISM OF THE ABDOMEN

1. Technique
○ Hand on surface = Pleximeter, Hand used to tap = Plexor/Dominant Hand
○ Force from the wrist, use middle finger
○ Direction: horizontal/radial (from umbilicus)/vertical
2. Findings
○ “Abdomen is generally tympanitic.”

B. LIVER DULLNESS

1. Technique
i. Determine lower border of Liver
○ Start below the umbilicus/RLQ, going up
○ Go up and down if unsure
○ Inform patient then, mark with a pen lower border of the liver
○ Tympanitic → Dullness
ii. Determine upper border of Liver
○ Start at 3rd ICS
○ Mark the upper border again
○ Resonance → Dullness
iii. Measure with measuring tape/ruler
2. Findings

ha n re. ♡
[MED201] CLINICAL MEDICINE

○ “The liver span is 10 cm.”

○ Normal liver span: 6-12 cm.

C. SPLENIC DULLNESS - TRAUBE’S SPACE

1. Delineate the border of Traube's space

○ Identify the Boundaries
○ Superior
■ Left 6th Rib
○ Lateral
■ Left MAAL
○ Inferior
■ Left Costal Margin
2. Percussion of Traube's space
3. Findings
○ “Traube’s space is intact. There is no obliteration. Hence no
splenomegaly.”

D. FIST PERCUSSION

1. Liver Fist Percussion

➢ Technique

○
➢ Findings
○ Used to check for liver tenderness when liver is not palpable
2. Splenic Fist Percussion
➢ Technique
i. Nixon’s Technique
○ Right lateral decubitus
○ Normal dullness 6-8 cm over costal margin.
○ >8 cm = splenomegaly
ii. Castell’s Technique
○ Supine, percuss lowest ICS (8-9th) along LAAL

ha n re. ♡
[MED201] CLINICAL MEDICINE

○ Deep inspiration and expiration

○ Normal resonance at 8th and 9th ICS during inspiration +
expiration
○ Dullness = +ve percussion sign
iii. Percussion of Traube’s Space
iv. Percussion along Midaxillary Line
○ Percuss along LMAL 9-11th ICS for Splenic Dullness
○ Begin at areas of lung resonance
➢ Findings
○ Used to check splenic dullness

E. COSTOVERTEBRAL ANGLE TENDERNESS - The Kidney Punch

○ Test for Acute Pyelonephritis
○ [usually part of special exam, but following checklist here]

1. Right Kidney
➢ Delineate Right Costovertebral Angle
➢ Technique
○ Appreciate 12th rib and vertebral column; angle in b/w

○
○ Remember to use ULNAR SURFACE
➢ Findings
○ Patient perceives the blow as a thud, NOT pain/tenderness
2. Left Kidney
➢ Delineate Left Costovertebral Angle
➢ Technique
➢ Findings

ha n re. ♡
[MED201] CLINICAL MEDICINE

V. SPECIAL EXAM

A. TEST FOR ASCITES

1. Fluid Wave
➢ Technique

○
○ Patient - supine, Examiner - Patient’s right side
○ Ulnar side of patient’s hand/another in middle of abdomen
○ Left hand on Patient’s Right Flank
○ Tap/Firmly strike
○ Observe for fluid wave with fingertips
➢ Findings
○ “Negative for fluid wave.”
2. Shifting Dullness
➢ Technique

ha n re. ♡
[MED201] CLINICAL MEDICINE

○
○ Patient still on supine
○ Percuss over top of abdomen - tympanitic
○ Percuss down side of abdomen
○ Ask patient to turn on one side and wait for 5-10 minutes
○ Percuss from top to downwards

○
➢ Findings
○ “Negative for Shifting Dullness.”
3. Puddle’s Sign
○ Knee-chest position
○ PAINFUL for patient with ascites so usually skipped
○ Flick then use stethoscope to inspect sound
○ “No ascites.”

ha n re. ♡
[MED201] CLINICAL MEDICINE

B. TEST FOR ACUTE APPENDICITIS

1. Mc Burney's sign
➢ Technique
○ Palpate at McBurney’s Point
○ Line from umbilicus to ASIS, 1/3rd

○
➢ Findings
○ “Negative for McBurney’s sign.”
2. Blumberg's sign
➢ Technique
○ Do it right after McBurney’s Sign Test
○ Pull hand back rapidly
○ Check for rebound tenderness
○ Ask which one is more painful: hand pressed or released?
○ Pain greater upon release for +ve rebound tenderness

○
➢ Findings
○ “Negative for Blumberg’s sign.”

ha n re. ♡
[MED201] CLINICAL MEDICINE

3. Rovsing's sign
➢ Technique
○ Press on the LLQ and release
○ Ask patient if pain is felt on RLQ

○
➢ Findings
○ “Negative for Rovsing’s sign.”
4. Markle's sign - Jar Tenderness
➢ Technique
i. Press and ask patient to cough 3 times
○ Ask patient if it hurts
ii. [Alt.] Ask patient to tip toe and drop forcefully on their heels

○
iii. If pain in RLQ, (+) Jar/Markle’s sign
➢ Findings
○ “Negative for Markle’s Sign.”
5. Psoa's sign
➢ Technique
○ Apply pressure above the knee
○ Ask patient to flex hips and knee
○ Right Hip Extension

○
○ [Alt: Ask patient to lift flexed knee and ask for pain in the RLQ]
➢ Findings
○ “Negative for Psoa’s sign.”
6. Obturator sign

ha n re. ♡
[MED201] CLINICAL MEDICINE

➢ Technique
○ Flex right leg at hip and knee at 90º in supine position
○ Internal rotation

○
➢ Findings
○ “Negative for Obturator sign.”

C. TEST FOR ACUTE CHOLECYSTITIS

1. Murphy’s sign
➢ Technique
○ Place fingers of right hand under Right Costal Margin
○ Ask patient to take a deep breath while gliding fingers upwards
○ Observe patient’s breathing and note degree of tenderness

○
○ Instead of asking if there is pain, note if there is extreme
tenderness
○ +ve if pain on inspiration
➢ Findings
○ “Negative for Murphy’s sign.”
2. Boa’s sign
➢ Technique

ha n re. ♡
[MED201] CLINICAL MEDICINE

○ Light touch on right costophrenic angle

○
○ Lift skin fold/stroke with sharp object (e.g. pen tip)
○ Referred pain for gallbladder
➢ Findings
○ “Negative for Boa’s sign.”

ha n re. ♡