Year Level 5

GI Nutrition Module
School Year 2019-2020
Guide to the Physical Examination of the Abdomen
Module Coordinator: Michele Rivera Nuez

The major components of the abdominal exam include observation, auscultation, percussion, and palpation.
In this activity, the students should be able to gain mastery in performing an abdominal examination.
Access to either references or notes in any form including electronic gadgets will be allowed during this
activity.

At the end of the activity, each student should be able to perform a complete abdominal examination in 20-
25 minutes. The students should also be able to answer important questions related in the conduct of the
Physical Examination of the Abdomen.

Materials Needed

• A Stethoscope
• Ruler/Tape Measure

General Considerations

• The patient should have an empty bladder.

• The patient should be lying supine on the exam table and appropriately draped.
• The examination room must be quiet to perform adequate auscultation and percussion.
• Watch the patient's face for signs of discomfort during the examination.
• Use the appropriate terminology to locate your findings:
o Right Upper Quadrant (RUQ)
o Right Lower Quadrant (RLQ)
o Left Upper Quadrant (LUQ)
o Left Lower Quadrant (LLQ)
o Midline:
▪ Epigastric
▪ Periumbilical
▪ Suprapubic
• Disorders in the chest will often manifest with abdominal symptoms. It is always wise to examine
the chest when evaluating an abdominal complaint.
• Consider the inguinal/rectal examination in males. Consider the pelvic/rectal examination in
females.

Inspection

• note the shape of the patient’s abdomen

o Symmetrical
o / Flat/ Rounded/ Protuberant/ scaphoid
o localized bulges? Bulging Flanks
• note the appearance of the skin over the abdominal area. Look for scars, striae, hernias, vascular
changes, lesions, or rashes. Few dilated veins are normally present;
• Noted the appearance of the Umbilicus.
o Color ( skin color/pinkish/bluish/purplish)
o Contour ( recessed, inverted, protruding)
o Location ( midline/any deviation)
o Signs of inflammation
o Hernia
o Caput medusae
o Identify and locate the umbilicus – normally about L3 to L5.
• Look for movement associated with visible peristalsis or pulsations.

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Auscultation

• Place the diaphragm of your stethoscope lightly on the abdomen.

• Auscultation should be done prior to percussion and palpation since bowel sounds may change
with manipulation.
• Since bowel sounds are transmitted widely in the abdomen, auscultation of more than one
quadrant is not usually necessary.
• Listen for bowel sounds. Three things should be noted:

1. Are bowel sounds present? Is it normal, increased, decreased, or absent

2. If present, are they frequent or sparse (i.e. quantity) Normal 5-34 min.
3. What is the nature of the sounds (i.e. quality) clicks and gugles if normal,
Borborygmi-long prolonged gurgles of hyperperistalsis.

• Listen for bruits over the renal arteries, iliac arteries, and aorta.

o Aortic bruits at the epigastrium

o Renal bruits at the over each Upper Quadrant
o Iliac bruits at the over each Lower Quadrant
o Femoral bruits at the Inguinal Areas

• Listen for friction rubs over the liver and spleen

o Rubs are infrequently found on abdominal examination but can occur over the liver, spleen,
or an abdominal mass.
o Patient is placed supine. Light pressure of the examining hand is used to feel a thrill over
the liver which is related to respiration. If felt, a friction rub will be heard, but a rub more
often is heard and not felt.

o A hepatic friction rub is very similar to the sound produced by forcibly rubbing the thumb
and forefinger together close to the ear.
• Demonstrate how to illicit succusion splash
o Succussion splash which is a splash-like sound heard over the stomach usually in the left
upper quadrant of the abdomen on shaking the patient, with or without the stethoscope.
o A succussion splash sounds like shaking a half-filled water bottle.
o Shake the abdomen and this can be done by lifting the patient with both hands under the
pelvis. Explain first what you are going to do.
o An audible splash more than 4 hours after the patient has eaten or drunk anything,
indicates delayed gastric emptying, e.g. pyloric stenosis or gastric outlet obstruction. ( from
Macleod’s Clinical Examination 11th Edition)

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Percussion

• Student should perform Inspection and auscultation first before he/she proceeded with percussion
or palpation
• Percussion of the abdomenis the same as that used for the lung exam. Rub the hands together
and warm them up before placing them on the patient. Place the left hand firmly against the
abdominal wall such that only your middle finger is resting on the skin. Strike the distal
interphalangeal joint of the left middle finger 2 or 3 times with the tip of your right middle finger, in a
floppy wrist action

• Percuss in all four quadrants using proper technique to assess distribution of tympany and dullness.

• Categorize what you hear as tympanitic or dull. Tympany is normally present over most of the
abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass.

Tympany
Below

Liver Span

• Technique:

o In the midclavicular line, percuss from lung resonance down toward the top edge of the
liver dullness (mark it).

o At a level below the umbilicus also in the midclavicular line (in an area of tympany) percuss
upward until you detect the bottom edge of liver dullness (mark it).

o Measure in centimeters the distance between the two points.This measurement should be 6-
12 cm in a normal adult.

o Span is increased in liver enlargement and decreased when liver is small or when free air is
present below the diaphragm as in perforated viscus.

o LS is falsely increased by R pleural effusion or consolidated lung adjacent to liver dullness.

o LS is falsely decreased by colonic gas.

Splenic Dullness

• Percuss the left lower anterior chest wall between lung resonance above and the costal margin, an
area termed as Traube’s space. Resonance in the Traube’s space make splenomegaly unlikely.
• The Traube’s space is bounded by:
o left anterior axillary line,
o 6th rib
o costal margin

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 o
• Castell’s Method is an alternative physical examination maneuver to percussion over Traube’s
space to evaluate splenomegaly. When the patient inspires, the spleen moves inferiorly along the
posterolateral abdominal wall. If the spleen is enlarged enough that the inferior pole reaches the
eighth or ninth intercostal space, a dull percussion note will be appreciated, indicating
splenomegaly.
o Place the patient in the supine position. With the patient in full inspiration and then full
expiration, percuss the area of the lowest intercostal space (eighth or ninth) in the left
anterior axillary line. When the percussion notes changes from resonant on full expiration
to dull on full inspiration there is a Positive Castell’s sign.
•

Palpation
General Palpation

• Begin with light palpation. At this point, report for any irregularities of the abdominal wall such as
lipomas or hernias, areas of tenderness, muscular spasm or rigidity.

o The most sensitive indicator of tenderness is the patient's facial expression (so watch the
patient's face, not your hands).
o Voluntary or involuntary guarding may also be present.

• Proceed to deep palpation after surveying the abdomen lightly. Place the flat of the hand on the
abdominal wall and applying firm, steady pressure. Alternatively, a two-handed palpation may be
done.In the two-handed palpation, the upper hand is used to exert pressure, while the lower hand
is used to feel.
• Try to identify abdominal masses, abdominal wall masses or areas of deep tenderness
o When abdominal masses are palpated, the first consideration is whether the mass is intra-
abdominal or within the abdominal wall.
o This can be determined by having the patient raise his or her head or feet from the
examining table. This will tense the abdominal muscles, thus shielding an intra-abdominal
mass while making an abdominal wall mass more prominent.
o If the mass is intra-abdominal, important points are its size, location, tenderness, and
mobility.
• One should start deep palpation in the quadrant directly opposite any area of pain and carefully
examine each quadrant. At each costal margin it is helpful to have the patient inspire deeply to aid
in palpation of the liver, gallbladder, and spleen

Palpation of the Liver

Standard Method

• Initial palpation is done lightly. Start at the right upper quadrant, 10 centimeters below the rib
margin in the mid-clavicular line then gently push downwards and upward towards the patient's
head with the hand oriented roughly parallel to the rectus muscle trying to feel the edge of the liver

• Repeat the examination with a deeper palpation on the same region by firmly pushing up and in
while the patient takes a deep breath. Deep inspiration will make the liver edge easier to feel as the
downward movement of the diaphragm will bring the liver towards your hand. On inspiration, the
liver is palpable about 3 cm below the right costal margin in the midclavicular line.

• You may feel the edge of the liver press against your fingers. Or it may slide under your hand as
the patient exhales. A normal liver is not tender

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Alternate Method

This method is useful when the patient is obese or when the examiner is small compared to the patient.

o Stand by the patient's chest.

o "Hook" your fingers just below the costal margin and press firmly.
o Ask the patient to take a deep breath.
o You may feel the edge of the liver press against your fingers.

Palpation of the Spleen

• Normally the spleen is not palpable. If there is NO dullness noted along the Traube’s space on
percussion, the spleen is unlikely to be enlarged. When enlarged, it tends to grow down towards
the pelvis and the umbilicus.

• The spleen is not so definitively bordered (like the liver) and thus has a tendency to float away from
you as you palpate.

• Place the patient in the supine position. Examine in a slow, gentle fashion. Begin by palpating near
the belly button and move slowly towards the ribs. Palpate superficially and then more deeply.
Then start 8-10 cm below the rib margin and move upwards. In this way, you will be able to feel
enlargement in either direction. Use your left hand to push in from the patient's left flank, directing
an enlarged spleen towards your right hand.

• Repeat the exam with the patient turned onto their right side, which will drop the spleen down
towards your examining hand.

• If the spleen is very big, you may even be able to "bounce" it back and forth between your hands.
The edge, when palpable, is soft, rounded, and rather superficial.

Palpation of the Kidneys

• To palpate for the Right Kidney, place the right (examining) hand at the inferior and lateral border
of the ribs then place the left hand on the lower ribs of the flank.. Push down your right hand as you
push up from behind with your left hand to bring the retroperitoneal contents up to the examining
hand. The exploration for the left kidney is performed in the same fashion as described for the
right.

• If the kidneys are massively enlarged, you may be able to feel it between your hands

Costovertebral Tenderness

When the patient's history is suggestive of a kidney infection, check for costo-vertebral angle tenderness.
CVA tenderness is often associated with renal disease.

o Warn the patient what you are about to do.

o Have the patient sit up on the exam table.
o Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.
o Compare the left and right sides.

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Palpation of the Aorta

1. Press down deeply in the midline above the umbilicus.

2. The aortic pulsation is easily felt on most individuals.
3. A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm.

Rebound Tenderness

• Abdominal tenderness is the objective expression of pain from palpation.

• Rebound tenderness refers to pain upon removal of pressure rather than application of pressure to
the abdomen.
• This is a test for peritoneal irritation. Warn the patient what you are about to do.

o Press deeply on the abdomen with your hand.

o After a moment, quickly release pressure.
o If it hurts more when you release, the patient has rebound tenderness.

• During palpation, smoothly but quickly lift the palpating hand off the patients’ abdomen while
observing for pain, facial grimace, or spasm of the abdominal wall. The examiner should avoid
removing his/her hand very quickly with an exaggerated motion and thus startling the patient .

• Positive Rebound tenderness is indicative of peritonitis. It represents aggravation of the

parietal layer of peritoneum by stretching or moving.

• Spasm or rigidity is the involuntary tightening of the abdominal musculature that occurs in response
to underlying inflammation.

• Guarding, in contrast, is a voluntary contraction of the abdominal wall musculature to avoid pain.
Thus, guarding tends to be generalized over the entire abdomen, whereas rigidity involves only the
inflamed area. Guarding can often be overcome by having the patient purposely relax the muscles;
rigidity cannot be. Rigidity is thus a clear-cut sign of peritoneal inflammation

Shifting Dullness

• This is a test for peritoneal fluid (ascites). Of the techniques used to detect ascites, assessment for
shifting dullness is perhaps the most reliable and reproducible. This method depends on the fact
that air filled intestines will float on top of any fluid that is present

o With the patient supine, begin percussion at the level of the umbilicus and proceed down
laterally. In the presence of ascites, you will reach a point where the sound changes from
tympanitic to dull. This is the intestine-fluid interface and should be roughly equidistant
from the umbillicus on the right and left sides as the fluid layers out in a gravity-dependent
fashion, distributing evenly across the posterior aspect of the abdomen. It should also
cause a symmetric bulging of the patient's flanks.
o Mark this point on both the right and left sides of the abdomen and then have the patient
roll into a lateral decubitus position (i.e. onto either their right or left sides).
o Repeat percussion, beginning at the top of the patient's now up-turned side and moving
down towards the umbilicus. If there is ascites, fluid will flow to the most dependent portion
of the abdomen. The place at which sound changes from tympanitic to dull will therefore
have shifted upwards (towards the umbillicus) and be above the line which you drew

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 previously. If the distention is not caused by fluid (e.g. secondary to obesity or gas alone),
no shifting will be identifiable
o
• If the dullness has shifted to areas of prior tympany, the patient may have excess peritoneal fluid.
Small amounts of peritoneal fluid are not usually detectable on physical exam. A change in the
level of dullness usually indicates more than 500 ml of ascitic fluid

Fluid Wave

Test for transmitted fluid wave when observation and/or percussion are suggestive of ascites.

• Ask the patient or an observer to place their hand so that it is oriented longitudinally over the center
of the abdomen. They should press firmly so that the subcutaneous tissue and fat do not jiggle.
The examiner places his/her right hand on the left side of the patients’ abdomen and the left hand
opposite, so that both hands are equidistant from the umbilicus. The examiner firmly tap on the
abdomen with the right hand while the left remains against the abdominal wall.

• If there is a lot of ascites present, a fluid wave (generated in the ascites by the tapping maneuver)
may be felt striking against the abdominal wall under the left hand.

Psoas sign

This is a test for appendicitis.

o Place your hand above the patient's right knee.

o Ask the patient to flex the right hip against resistance.
o Increased abdominal pain indicates a positive psoas sign.

• Positive Psoas sign indicates irritation to the iliopsoas group of hip flexors in the abdomen, and
consequently indicates that the inflamed appendix is retrocaecal in orientation (as the iliopsoas
muscle is retroperitoneal).

Obturator Sign

This is a test is performed when acute appendicitis is suspected.

o Put the patient on her/his back with the hip and knee both flexed at ninety degrees.
o The examiner holds the patient's ankle with one hand and knee with the other hand.
o the examiner internally rotates the hip by moving the patient's ankle away from the
patient's body while allowing the knee to move only inward. This is flexion and internal
rotation of the hip

• Positive Obturator Sign produces pain on passive internal rotation of the flexed thigh. In this
condition, the appendix becomes inflamed and enlarged and may come into physical contact with
the obturator internus muscle. This maneuver will stretch the OIM when performed on the right leg
causing pain.

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Rovsing's Sign

• As in most people the appendix is in the right lower quadrant. A Rovsing's sign is elicited by
pushing on the abdomen far away from the appendix in the left lower quadrant. Tenderness felt in
the RLQ when palpation is performed on the left is called and suggests appendicitis.

o Press deeply and evenly in the left lower quadrant. Deep palpation of the left lower
quadrant may produce tenderness and rebound tenderness in the right lower quadrant

• While this maneuver stretches the entire peritoneal lining, it only causes pain in any location where
the peritoneum is irritating the muscle. In the case of appendicitis, the pain is felt in the right lower
quadrant despite pressure being placed elsewhere

Murphy’s sign

This is a test for cholecystitis.

o Ask the patient to breathe out and then gently place the examining hand below the costal
margin on the right mid-clavicular line at the approximate location of the gallbladder.
o Ask the patient to inspire (breathe in). If the patient stops breathing in and winces with a
'catch' in breath, the test is considered positive.
o During inspiration, the abdominal contents are pushed downward, as the gallbladder
is tender and in moving downward it comes in contact with the examiner's fingers causing
pain and arrest in inspiration.
o Sonographic Murphy sign:
o When performing diagnostic medical sonography. When the sonographer
presses directly over the gallbladder and the patient expresses pain, more than
when the sonographer presses anywhere else, this is said to be a positive
sonographic Murphy sign

For more information, refer to A Guide to Physical Examination and History Taking, Tenth Edition
by Barbara Bates, published by Lippincott in 2009.

https://www.youtube.com/watch?v=_zlZj_f_XNk

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