Abdominal Examination

Ideal exposure of the abdomen:

from nipple to mid-thigh but for the privacy of the patient

we do exposure from the Xiphoid process to Symphesis
pubis.
 Introduce yourself.
 Take permission to examine the patient.
 Tell about exposure & position.

1- Exposure
 Ideal exposure from nipple to mid thigh.

 For the privacy of the patient expose from Xiphoid process to

Symphesis-pubis.
 Position of the patient:

 Patient centralized in bed, in a flat & supine position.

 Have the patient keep arms at the sides.

 2- INSPECTION:
 Look at the patient once from the end of the bed and see the
followings:
1. Abdominal contour. (Normal, distended or scaphoid).
2. Symmetry. (Symmetrical or there is a localized bulge).
3. Movement with respiration. (Freely mobile or restricted).
( Normal contour, symmetrical abdomen , freely mobile with respiration )
 Then look for:
1- Sub-costal angle. (Normally 90 to 110)
2- Epigastrium. (Epigastric pulsation tangentially) HOLD YOUR
BREATH please.
3- Umbilicus.(Site, shape, scar, discharge, nodule, and peri-
umbilical dilated veins)
4- Hair distribution (Male “tringle”, female “inverted triangle”).
6- Skin of the abdomen (scars, scratch marks, striae )
Normal subcostal angle = 90 – 110
Dilated veins (Caput medusa)
Umbilical
nodule
 Before you finish with your inspection, ask
the patient to do 2 things:
1. Ask him to cough to see Hernial orifices (Epigastric,
umbilical, para-umbilical, inguinal and femoral hernia).

2. Get up unsupported to see

divarication of recti.
The umbilicus:

Shape normally inverted,

Site normally midway between Xiphoid process and Symphesis pubis.

Umbilical discharge.

Umbilical nodule.

Umbilical scar: in previous surgery.

Caput Medusa: in Portal hypertension.

Comment (umbilicus is inverted, midway between xiphoid

process and symphysis pubis, no discharge, no scars, no
nodules and no dilated veins )
 3- PALPATION
Palpation of the abdomen should be
performed in a systematic way
using the 9 named segments of
the abdomen:
• Right and left hypo-chondrium,
• Right and left lumbar,
• Right and left iliac fossa,
• Umbilical area,
• Epigastrium
• Supra-pubic region.
If a patient has pain in one
particular area you should start as
far from that area as possible.
 What to palpate?

 Superficial palpation  Deep palpation :

 9 quadrant.
 Deep organ ( liver ,
spleen and kidneys).

•Warm your hands.

•Wear Gloves.
•Ask about site of pain.
•Keep eye contact with the patient (to
detect tenderness)
 Superficial abdominal Palpation
Initial examination should be superficial using one hand
AIMING TO:

1- Get confidence of the patient.

2-Detect superficial tenderness.

3-Detect superficial masses.

Place the hand flat over each area. Palpate by flexing the
metacarpophalangeal joint. You should always be looking at
the patient's eyes for any signs of superficial tenderness.
Superficial abdominal Palpation

Where to start? Away from site of

pain.

The aim? 3

Precautions: Warm your hand &

look to the patient face

 Deep abdominal Palpation.
AIMING TO:
1. Deep abdominal tenderness.
2. Deep abdominal masses
3. Organomegally.

Again using the palmer surfaces of

your fingers, feel in all 9
quadrants.
Deep abdominal Palpation.
Palpation of the liver:
 Rt lobe of the liver:
 Start palpation with the edge of
your fingers from right iliac To differentiate measure liver
fossa at the mid-clavicular line.
 Ask the patient to take deep span by detection of upper
breathing.
 Go up gradually with every border of the liver by heavy
breath until you feel lower
border of the liver . percussion
 If you feel it , this means
hepatomegaly , measure in cm
below the costal margin in mid-
clavicular line.

oLeft lobe of the liver:

By your finger tips in midline
starting at the umbilicus upwards
toward the Xiphoid process
Palpation of lower border of right
lobe of liver

Where to start? From right iliac

fossa.
What is the normal length of liver
span?
Palpation of the spleen:
 Begin from RT iliac fossa with your finger tips crossing
the umbilicus toward left costal margin.

 Ask patient to take deep breathing.

 If not felt:

1. Bimanual method.

2. Hooking method.
Hooking method of splenic
palpation.
Limitations: Painful
 Palpate the kidneys
 1. Place your left hand behind the patient’s back, below
the ribs.
 2. Then place your right hand on the anterior abdominal
wall just below the right costal margin.
 3. Push your fingers together, pressing upwards with
your left hand and downwards with your right hand.
 4. Ask the patient to take a deep breath and as they do
this feel for the lower pole of the kidney moving down
between your fingers.
Right kidney palpation Left kidney palpation
 3- Percussion
What to percuss in the abdomen: ORGANS & ASCITES
1- for ascites:
• Moderate ascites: Bilateral shifting dullness.
• Tense ascites: Transmitted fluid thrill.
Bilateral Shifting Dullness
First: make sure that urinary bladder is empty. (HOW??)
Then: With the patient lying flat, start percussion from the
midline away from you. If the percussion note changes (from
resonant to dull), hold you finger in that position and ask the
patient to roll towards you. Again <after about 15 seconds>
percuss over this area again and if the note has changed
(became resonant again) then it suggests presence of
moderate fluid such as in ascites.
Name of this part of examination: Percussion for ascites.
Name of the test: Bilateral shifting dullness test.
Diagnosis in case of positive test: Moderate ascites.
Name of this part of examination: Percussion for ascites.
Name of the test: Transmitted fluid thrill test.
Diagnosis in case of positive test: Tense ascites.
 AUSCULTATION
Place the diaphragm of your stethoscope gently on the
abdomen. Listen for bowel sounds and note their
frequency and character. Normal sounds occurs at an
estimated frequency of 2 to 3 per minute.

Best place to auscultate is the right lower quadrant, 3 Cm

away from umbilicus.