ABDOMINAL ASSESSMENT
Subjective Data (Patient Questions)
1. Any changes in your appetite?
o
Possible Symptoms/Conditions:

Anorexia (loss of appetite) can be linked to systemic illnesses like infections,
cancer, or gastrointestinal (GI) diseases like Crohn's disease.

Increased appetite (hyperphagia) may indicate metabolic disorders like diabetes
mellitus or hyperthyroidism.
2. Any difficulty swallowing?
o
Possible Symptoms/Conditions:

Dysphagia (difficulty swallowing) can be caused by neurological conditions like
stroke, esophageal strictures, or GERD (gastroesophageal reflux disease).

Odynophagia (painful swallowing) could indicate infection or inflammation of
the esophagus, such as in esophagitis.
3. Any foods you cannot tolerate?
o
Possible Symptoms/Conditions:

Lactose intolerance: Common difficulty digesting dairy products.

Food allergies: Could cause nausea, vomiting, or abdominal cramps.

Gluten sensitivity or Celiac disease: Often associated with bloating, diarrhea,
and abdominal pain after consuming gluten-containing foods.
4. Any abdominal pain?
o
Possible Symptoms/Conditions:

Pain could be linked to a variety of conditions such as gastritis, peptic ulcers,
appendicitis, or irritable bowel syndrome (IBS).

Pain in the upper abdomen could be related to liver or gallbladder disease.

Referred pain from other organs (e.g., heart attack could cause epigastric pain).
5. Any nausea or vomiting?
o
Possible Symptoms/Conditions:

Nausea/vomiting can be caused by infections (like gastroenteritis), food
poisoning, or other GI disorders.

Chronic vomiting could indicate a metabolic disorder, peptic ulcers, or even
pregnancy.
6. How often are bowel movements?
o
Possible Symptoms/Conditions:

Constipation may indicate IBS, hypothyroidism, or bowel obstruction.

Diarrhea can result from infections, stress, food intolerances, or conditions like
IBS, Crohn's disease, or ulcerative colitis.
7. Any past history of GI disease?
o
Possible Symptoms/Conditions:

Previous history of Crohn's disease, ulcerative colitis, or irritable bowel
syndrome (IBS) would be relevant to current symptoms.

History of gastrointestinal bleeding (e.g., peptic ulcers, diverticulosis).
8. What medications are you taking?
o
Possible Symptoms/Conditions:

Certain medications such as NSAIDs can cause GI irritation, ulcers, and bleeding.

Antibiotics might lead to diarrhea due to changes in gut flora.

Opioids can cause constipation.
9. 24-hour diet recall
o
Possible Symptoms/Conditions:

Helps identify potential food intolerances or allergies.

High-fat or spicy foods might trigger gastroesophageal reflux disease (GERD) or
gallbladder disease.

Low-fiber intake could indicate potential constipation.
Objective Data (Physical Examination)
Inspection
1. Stands on right side, should be eye level
o
Ensures that the examiner views the abdomen from an appropriate angle.
2. Contour of abdomen
o
Describe: Look for flat, scaphoid (sunken), distended, or protruding (e.g., due to
bloating or ascites).
o
Possible Symptoms/Conditions:

Distension could be from gas or fluid accumulation (ascites due to liver disease,
heart failure).

Scaphoid abdomen could suggest malnutrition or dehydration.
3. General Symmetry
o
Shine light towards self: Symmetry helps assess for masses, hernias, or abnormal
protrusions.
o
No bulging/masses: Bulging might indicate hernia, tumors, or organomegaly.
4. Skin color and condition
o
Smooth, even, pink: Normal, healthy skin tone.
o
Check for scars, striae, nevi: Scars may suggest prior surgery or trauma, and striae
(stretch marks) might indicate rapid weight gain or pregnancy. Nevi (moles) could be
benign or indicative of melanoma if irregular.
5. Pulsation or Movement
o
May be able to see aortic pulse in epigastric area: This is a normal finding but should not
be exaggerated.
o
Possible Symptoms/Conditions: Excessive pulsations may indicate abdominal aortic
aneurysm (AAA).
6. Umbilicus
o
Midline, inverted: The umbilicus should be central and not bulging or protruding.
o
Possible Symptoms/Conditions: A protruding umbilicus may indicate umbilical hernia or
ascites.
7. State of hydration and nutrition
o
Check skin turgor: Decreased skin turgor may indicate dehydration.
o
Possible Symptoms/Conditions: Poor nutrition or dehydration may lead to dry skin or
poor wound healing.
8. Person’s facial expression and position in bed
o
Relaxed, slow, even respirations: A relaxed expression and slow breathing usually
indicate no acute distress.
o
Possible Symptoms/Conditions: Tense facial expressions or rapid breathing might
indicate pain or discomfort from abdominal issues.
Auscultation
1. Bowel Sounds
o
Normal 5-30/min. Auscultate for at least 5 minutes to assess for absent bowel sounds.
o
Possible Symptoms/Conditions:

Hypoactive or absent bowel sounds could suggest paralytic ileus, peritonitis, or
bowel obstruction.

Hyperactive sounds may be a sign of gastroenteritis or early bowel
obstruction.
2. Vascular Sounds
o
Check for bruit over aorta, renal, iliac, and femoral arteries: Use the bell of the
stethoscope for vascular sounds.
o
Possible Symptoms/Conditions:

A bruit may indicate turbulent blood flow, which could be due to vascular
stenosis or an aneurysm.
Percussion
1. Percusses in all four quadrants
o
Tympany throughout: This is normal in a healthy abdomen as it indicates the presence
of gas in the intestines.
o
Possible Symptoms/Conditions:

Dullness in certain areas may indicate the presence of fluid (ascites) or masses
(tumors, enlarged organs).
Palpation
1. Light Palpation
o
No tenderness or masses.
o
Possible Symptoms/Conditions:

Tenderness might indicate inflammation or infection in the abdominal organs,
such as appendicitis or cholecystitis.

Masses could be indicative of tumors, enlarged organs, or cysts.
2. Deep Palpation
o
Masses: If detected, note size, location, and consistency.
o
Possible Symptoms/Conditions:

An enlarged liver or spleen could be a sign of hepatitis, cirrhosis, or
splenomegaly.
3. Rebound Tenderness
o
Testing for peritoneal irritation (e.g., appendicitis, peritonitis).
Additional Tests
1. Murphy’s Test (Inspiratory Arrest)
o
Used to detect gallbladder inflammation (cholecystitis).
o
Possible Symptoms/Conditions: Positive test may indicate gallstones or cholecystitis.
2. Iliopsoas Muscle Test
o
Used when appendicitis is suspected.
o
Possible Symptoms/Conditions: Pain on the test may indicate appendicitis.