Notes on Objective Physical Exam of the Abdomen

Objective Physical Exam of the Abdomen

Overview of the Examination Process

  • Different Order for Abdomen: The order of examination for the abdomen differs from that of other body systems.

  • Mnemonic to Remember the Order: IAPP

    • I - Inspection

    • A - Auscultation

    • P - Percussion

    • P - Palpation

  • Reason for Order:

    • Auscultation is performed before palpation to avoid altering bowel motility. Pressing on the abdomen can stimulate bowel sounds, leading to inaccurate auscultation results.

Step 1: Inspection

  • Initial Assessment: Inspect the bare abdomen of the patient.

  • Patient's Abdomen Contour: Look for the generalized shape of the abdomen from rib cage to hip bone.

    • Types of Contour Shapes:

      • Flat: Straight line from rib cage to hip bones.

      • Scaphoid: A sunken appearance, often seen in malnourished patients, suggesting a "void" where tissue is absent.

      • Rounded: Indicates overweight status, early pregnancy signs, or normal infant appearance (infant pot belly).

      • Protuberant: Abdominal distension, often in third trimester pregnancy, ascites, or morbid obesity.

  • Practice Question: What type of abdomen does a two-year-old child typically have?

    • Answer: Protuberant.

  • Symmetry and Abnormal Findings:

    • Check for symmetry between left and right sides of the abdomen.

    • Watch for bulging, pulsations, or changes during Valsalva maneuver or coughing.

    • Look for any signs of herniation, especially around umbilicus or incisional areas.

  • Skin Assessment:

    • Assess skin tone, look for piercings, tattoos, or concerning moles.

    • Check for surgical scars as indicators of past operations.

    • Stretch Marks (Striae):

      • Fresh Marks: Purple/red/blue.

      • Older Marks: Silvery/white.

      • New stretch marks may suggest sudden fluid accumulation (ascites).

Step 2: Auscultation

  • Process of Auscultation:

    • Always begin in the right lower quadrant, moving in a clockwise fashion.

    • Listen for bowel sounds using the diaphragm of the stethoscope (this picks up louder sounds).

    • Sound Expectations: Look for clicks and gurgles, with normal activity:

      • Normal (Normoactive) Bowel Sounds: 5 to 30 clicks and gurgles per minute.

      • Hyperactive: More than 30 clicks, which indicates increased bowel activity (e.g., from coffee, laxatives, or early bowel obstruction).

      • Hypoactive: Less than 5 clicks. It may require listening for 20 minutes before determining absence of sounds.

  • Time Allocation: Spend 1 to 1.5 minutes in each quadrant for a thorough assessment.

  • Key Terms:

    • Borborygmi: Loud, gurgling sounds often heard when hungry, indicative of hyperactive bowel sounds.

    • Ileus: Minimal or no bowel activity, characterized by absent or hypoactive sounds, often requiring an NG tube.

Step 3: Percussion

  • Technique: Utilize indirect percussion with two hands in a zigzag pattern in each quadrant, starting from the right lower quadrant.

  • Sounds to Identify:

    • Tympany: Drum-like sound associated with the abdomen, similar to puffing out a cheek and tapping it.

  • CVA Tenderness:

    • Assess costo-vertebral angle by tapping over the joint between rib and vertebral column, known as the "kidney punch" test.

    • Pain may indicate kidney inflammation, infection, or stones.

Step 4: Palpation

  • Types of Palpation: Two methods, using light and deep palpation.

    • Light Palpation: Use one hand to feel 1-2 cm deep, watching for tenderness, bulging, or masses.

    • Deep Palpation: Use both hands to press 3 inches deep, searching for hidden masses or organ enlargement (organomegaly).

  • Technique for Liver Palpation:

    • Bimanual Technique:

      • Stand on the patient's right side, use one hand to lift the rib cage, the other to palpate under the costal margin during deep inhalation.

    • Hooking Technique:

      • At patient’s shoulders, hook fingers under rib margin and have the patient breathe in.

  • Assessment for Pain: Both liver palpation methods should not elicit pain.

Key Sequences and Procedural Notes

  • Sequence of IAPP: Follow the order - Inspection, Auscultation, Percussion, Palpation.

  • Assess the patient’s abdomen systematically, ensuring a comprehensive evaluation of all regions.

  • Pay attention to additional questions or assessments based on patient history and signs observed during initial inspection and assessment.