Detailed Abdominal Exam

Course Objectives

  • Learn the steps involved in a detailed abdominal examination.

  • Understand the importance of inspection, auscultation, percussion, and palpation in assessing abdominal health.

Order of Examination

  • Inspection - Look at the patient and abdomen first.

  • Auscultation - Listen to bowel sounds.

  • Percussion - Tap to assess underlying structures.

  • Palpation - Feel for abnormalities and organ sizes.

Inspection of the Abdomen

  • Ensure adequate exposure: from the zip void (xiphoid process) to pubis.

  • Skin Assessment: Look for scars, superficial veins, discoloration, or abnormalities.

  • Umbilicus Assessment: Check for hernias, shapes, or discoloration.

  • Contour of Abdomen: Note if it is flat, distended, or scaphoid. Look for pulsations or peristalsis.

  • Abnormalities: Identify signs of fluid accumulation or distension.

Auscultation

  • Critical to perform before palpation and percussion.

  • Listen in all four quadrants: right upper, right lower, left upper, left lower.

  • Normal Bowel Sounds: High-pitched, occurring every 3-5 seconds.

  • Absent Sounds: No sounds for 2 minutes.

  • (Borborigmy)Hyperactive Sounds: Indicate rapid gastrointestinal movement; low-pitched rumbling. It usually indicates hyperperistalsis. Things are quickly moving through the bowel.

  • Bruits: Soft blowing sounds from disrupted arterial flow; assess in several key locations. Turbulent arterial flow causing a soft blowing sound

Common Bruit Locations

  • Aortic: Midline, between xiphoid and umbilicus.

  • Renal Artery: Lateral to aorta.

  • Femoral Arteries: Near inguinal ligament.

  • Iliac Arteries: Laterally to umbilicus.

Percussion

  • Evaluate for gaseous distension, fluid, solid masses, liver, and spleen size.

  • Use a supine position; percuss all four quadrants.

  • Percuss along the right mid-clavicular line from the top to bottom.

  • Liver Percussion: Gauge resonance change:

    • Normal:

      • resonant near lungs

      • dull over the liver

      • tympanic over the intestines. Most common percusion note. It shows that there is gas in the stomach and in the bowel.

    • Hepatomegaly: Enlarged liver if more than 10 cm.

    • Normal Liver: Less than 10cm

  • Ascites:

    • When there is fluid in the abdomen

  • Assessing Ascites:

    • Fluid Wave Test: Place the patient’s hand in the midline. Tap one flank while palpating the opposite. An easy palpable pulse suggests ascites.

    • Shifting Dullness Test:

      • Percuss the pt on their back.

      • Note where the sound changes from tympany to dull.

      • As the patient is rolled; tympanic to dull as fluid shifts.

Palpation Techniques

  • Light Palpation: Use fingertips, check all quadrants first.

  • Deep Palpation: One hand over the other to assess deeper structures.

  • Assess for rebound tenderness, indicating peritoneal inflammation.

    • Rovsing's sign is a clinical sign that indicates appendicitis. It is typically tested by palpating the left side of the abdomen, which may cause pain in the right lower quadrant if appendicitis is present.

      • Referred rebound tenderness

Palpation Specifics

  • Murphy's Sign: Sudden cessation of breath during right upper quadrant palpation due to gallbladder inflammation.

  • Liver Palpation: Position: left hand on ribs, right hand pressing in during deep breath.

  • Spleen Palpation: Similar to liver; left hand under ribs, right hand in upper left quadrant.

  • Aorta Palpation: Firmly assess width; normal is 2.5 to 3 cm.

  • Kidney Palpation: 'Sandwich Method,' assessing for lower kidney with both hands.

  • CVA Tenderness Check: Assess for infection/inflammation by softly hitting the costovertebral angle.

Types of Abdominal Pain

  • Visceral Pain (Coilc Pain):

    • The source is usually a hollow organ.

    • It comes and goes, poorly localized due to organ distension.

  • Parietal Pain: Steady aching pain, well-localized due to peritoneal inflammation.

  • Referred Pain: E.g., gallbladder pain can refer to the right shoulder. Left shoulder to spleen, back pain referred to pancreas or aorta. Kidneys - groin and flanks (

  • Visceral Pain:

    • Localization: Poorly localized

    • Origin: Derived from hollow organs

    • Nerve pathway: Conveyed by autonomic nerves, which have a diffuse distribution

    • Characteristics: Vague and often hard to pinpoint

  • Parietal Pain:

    • Localization: Well localized

    • Origin: Arises from irritation of the peritoneum

    • Nerve pathway: Carried by somatic nerves, which are more precisely located

    • Characteristics: Steady and localized to the area of inflammation

Referral Patterns for Pain

  • Gallbladder: right shoulder.

  • Spleen: left shoulder (Kehr’s Sign).

  • Pancreas and Aorta: back.

  • Kidneys: groin/flanks.

  • Renal Colic Pain refers to the flank and groin

Digital Rectal Examination (DRE)

  • Patient Positions:

    • Modified lithotomy (Patient on their back)

    • Standing bent over the exam table

    • Sims position — Lying on the left side.

  • Inspection: Look for rashes, fissures, and hemorrhoids.

  • Procedure: Lubricate finger, gently insert, palpate as needed.

  • Assess fecal matter and prostate in male patients.

  • Conduct fecal occult blood testing for colorectal cancer screening, if FOBT (Fetal Occult Blood testing is positive).

    • Sigmoidoscopy and air contrast barium enema are acceptable alternatives

Documentation of Abdominal Exam

  • Flat, + RLQ 4-inch surgical scar

  • BS x 4, neg. aortic or femoral bruits

  • Tympanic percussion, neg. distension, liver 9 cm

  • Neg. tenderness or masses to superficial and deep palpation, aorta not enlarged

  • Neg. hepatosplenomegaly (HSM)or tenderness

  • Neg. CVA tenderness

  • Rectal: neg. external lesions, good sphincter tone, no masses or tenderness, stool for occult blood-negative