Abdominal Examination
H.A.Soleimani MD
Gastroenterologist
General principles of exam
Abdominal Examination
The History and Physical in
Perspective
70% of diagnoses can be made based on
history alone.
90% of diagnoses can be made based on
history and physical exam.
Expensive tests often confirm what is
found during the history and physical.
Equipment for physical examination
Required
Optional
Stethoscope
Tongue blades
Penlight
Tape measure
Sphygmomanometer
Reflex hammer
Safety pins
Gloves
Gauze pads
Lubricant gel
Nasal speculum
Turning fork: 128 Hz,512Hz
Pocket visual acuity
card
Oto-ophthalmoscope
Important aspects of physical
examination----physician
Elegant appearance
Decent manner
Kind attitude
Highly responsibility
Good medical
morals
Important aspects of physical
examination---physician
Wash your hands,
preferably while the
patient is watching
Washing with soap
and water is an
effective way to
reduce the
transmission of
disease
How to perform the physical
examination?
Exposing only the
area that are being
examined
Offer a chaperone for
both sexes.
Explain what you're
going to do
Sequential
Important aspects of physical
examination
The examiner should
continue speaking to
the patient
Showing care to his
disease and answer to
patient’s questions
It can not only release
patient’s nerviness, but
also help to establish
the good physicianpatient relationship
Gloves should be worn when..
Examining any
individual with
exudative lesions or
weeping dermatitis
When handling
blood-soiled or body
fluid-soiled sheets
or clothing
General principles of exam
Good light
Relaxed
patient
Full exposure
of abdomen
General principles of exam
Have the patient
empty their bladder
before examination
Have the patient lie in
a comfortable, flat,
supine position
Have them keep their
arms at their sides or
folded on the chest
General principles of exam
Before the exam, ask
the patient to identify
painful areas so that
you can examine
those areas last
During the exam pay
attention to their facial
expression to assess
for sign of discomfort
General principles of exam
Use warm hand,
warm stethoscope,
and have short finger
nails
Approach the patient
slowly and
deliberately
explaining what you
will be doing
General principles of exam
 Stand right side of the
bed
 Exam with right hand
Head just a little
elevated
Ask the patient to
keep the mouth
partially open and
breathe gently
General principles of exam
If muscles remain
tense, patient may
be asked to rest
feet on table with
hips and knees
flexed
Other helpful points on examination
Take a spare bed
sheet and drape it
over their lower body
such that it just
covers the upper
edge of their
underwear
General principles of exam
If the patient is ticklish
or frightened
Initially use the
patients hand under
yours as you palpate
When patient calms
then use your hands
to palpate.
Watch the patient’s
face for discomfort.
Think
Anatomically
Think Anatomically
When looking,
listening, feeling and
percussing imagine
what organs live in
the area that you are
examining.
Right Upper Quadrant (RUQ)
liver, gallbladder,
duodenum,
right kidney
and hepatic
flexure of colon
Right Lower Quadrant (RLQ)
Cecum,
appendix (in
case of female,
right ovary &
tube)
Left Lower Quadrant (LLQ)
Sigmoid
colon (in case
of female, left
ovary & tube)
Left Upper Quadrant (LUQ)
Stomach,
spleen, left
kidney, pancreas
(tail), splenic
flexure of colon
Epigastric Area
Stomach,
pancreas
(head and
body), aorta
Landmarks of the abdominal wall,
Costal margin,
umbilicus, iliac crest,
anterior superior iliac
spine, symphysis
pubis, pubic tubercle,
inguinal ligament,
rectus abdominis
muscle, xiphoid
process.
Physical Examination of the
Abdomen
Inspection
Auscultation
Percussion
Palpation
Special Tests
Inspection
Abdominal examination
Appearance of the abdomen
Is Aortic pulsation?
Is it flat or Scaphoid
(Normally)?
Distended?
If enlarged, does this
appear symmetric?
With bulging or
moving?
Symmetrical in shape
Scaphoid or flat in young
patients of normal weight
slightly full but not distended in older age
group due to poor muscle tone or in
subjects who are mildly overweight
Appreciation of abdominal contours
Standing at the foot of
the table and looking up
towards the patient's
head.
Lower yourself until the
anterior abdominal
wall and ask the patient
to breathe normally while
you are doing so.
Appearance of the abdomen
Global
abdominal
enlargement is
usually caused
by air, fluid, or
fat.
Appearance of the abdomen
Localized
enlargement
probably distend
GB space
occupying lesion,
hepatomegaly….
An aortic aneurysm
Palpable mass
Patient feeling of
pulsation
On rare occasions, a
lump can be visible.
An aortic aneurysm
1 in 10 men over 65
may have some
enlargement of the
abdominal aorta.
About 1 in 100 will
have a large
aneurysm requiring
surgery.
Appearance of the abdomen
(Skin)
Abnormal venous
patterns
Abnormal
discoloration
Umbilicus is sunken
Striae
Stretch marks are a
light silver hue.
Pregnancy and obese
individuals
Cushing’s syndrome
(more purple or pink).
Appearance of the abdomen
(Skin)
Tattoos
Scars can be drawn
on schematic
diagrams of the
abdomen (a picture is
worth a thousand
words).
Cullen’s sign
Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
Grey-Turner’s sign
Ecchymosis of
flanks.
(retroperitoneal
hemorrhage
such as
hemorrhagic
pancreatitis)
Upward flow direction indicates IVC obstruction
Outward flow pattern from umbilicus in all directions ? Portal HTN
Evaluate venous return states
Place index finger
side by side over a
vein and press
laterally, milking vein.
Release one finger
and time refill, repeat
with other finger.
Venous return is in
direction of faster
filling.
Appearance of the abdomen
Areas which
become more
pronounced when
the patient
valsalvas are
often associated
with ventral
hernias
Visible Pulsations
More conspicuous in the
thin than in the fat
Greater in the old than in
the young.
Increased in
thyrotoxicosis,
hypertension, or aortic
regurgitation)
In those with an aortic
aneurysm and tortuous
aorta
In those who have a
mass joining the aorta to
the anterior abdominal
wall.
Visible gastric Peristalsis
Visible intestinal Peristalsis
Gastric peristalsis is
commonly seen in
neonates with
congenital
hypertrophic pyloric
stenosis
Intestinal peristalsis in
partial and chronic
intestinal obstruction
Colonic obstruction is
usually not manifest
as visible peristalsis
Appearance of the abdomen
Patient's movement
Patients with kidney
stones will frequently
writhe on the
examination table,
unable to find a
comfortable
position
Appearance of the abdomen
Patient's movement
Patients with
peritonitis prefer to lie
very still as any
motion causes further
peritoneal irritation
and pain.
Auscultation
Abdominal examination
Auscultation
Bowel sounds
Vascular sounds (bruits)
Friction Rubs
Auscultation for bowel sounds
It is performed before percussion or
palpation
Auscultation for bowel sounds
Normal sounds are
due to peristaltic
activity.
Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
Auscultation for bowel sounds
Compared to the
cardiac and
pulmonary exams,
auscultation of the
abdomen has a
relatively minor role.
Auscultation for bowel sounds
Bowel sounds lend
supporting
information to other
findings but are not
pathognomonic
for any particular
process.
Auscultation
1.Diaphragm of
stethoscope
used
2.Skin
depressed to
approximately 1
cm
Auscultation
3.Listening in one
spot is usually
sufficient
4.Listening for 15-20
or 30-60 seconds
5.Bowel sounds cannot
be said to be absent
unless they are not heard
after listening for 3-5
minutes.
Three things about bowel
sound
Are bowel sounds
present?
If present, are they
frequent or sparse
(i.e.quantity)?
What is the nature of
the sounds
(i.e.quality)?
Bowel sound decrease
Inflammatory
processes of the
serosa
After abdominal
surgery
In response to
narcotic analgesics or
anesthesia.
Auscultation for bowel sounds
Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.
Auscultation for bowel sounds
Processes which
lead to intestinal
obstruction initially
cause frequent
bowel sounds,
referred to as
"rushes."
Auscultation for bowel
sounds
Processes which lead
to intestinal
obstruction initially
cause frequent bowel
sounds, referred to as
"rushes."
Auscultation for bowel sounds
“Rushes" means
as the intestines
trying to force
their contents
through a tight
opening.
Auscultation for bowel
sounds
“Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.
Auscultation for bowel
sounds
After silence the
appearance of bowel
sounds marks the
return of intestinal
sounds activity, an
important phase of
the patient's recovery.
Splash Sign
Splashing sound
indicative of air or
fluid in body cavity
with shaking
individual: normal in s
stomach.
Auscultation for bowel sounds
Bowel sounds,
then, must be
interpreted within
the context of the
particular clinical
situation.
Bruits
Bruits confined
to systole do not
necessarily
indicate disease.
Auscultation for vascular sounds
(bruits)
Aortic (midline between
umbilicus and xiphoid
Renal (two inches
superior to and two
inches lateral to
umbilicus)
Common iliac (midway
between umbilicus
and midpoint of
inguinal ligament)
Auscultation for vascular sounds
(bruits)
Presence of a bruit
on the renal artery
would lend
supporting
evidence for the
existence of renal
artery stenosis.
Auscultation for vascular sounds
(bruits)
When listening for
bruits, you will need
to press down quite
firmly as the renal
arteries are
retroperitoneal
structures.
Venous Hum (rare)
Epigastric/umbilical
area.
Soft humming noises
in systolic/diastolic
component.
Indicates collateral
between portal and
venous systems as in
hepatic cirrhosis.
Rubs –Rubs-Rubs
Liver
Spleen
Cardiac
Pulmonary
Friction rubs (rare)
Right and left upper
quandrants
Grating sound with
respiratory movement
Indicates
inflammation of the
capsule of the liver or
spleen (infection or
infarction).
Percussion
Abdominal examination
Percussion
Technique
Liver
Spleen
Percussion (technique)
DIP joint of third
finger (pleximeter)
pressed firmly on the
abdomen remainder
of hand not touching
the abdomen
Percussion (technique)
Striking hand
should move
only at the wrist,
with only little
more than force
of gravity
Percussion (technique)
Middle finger of
striking hand
(plexor) should
knock the
pleximeter firmly,
with a strong
note
There are two basic sounds with
Percussion
Tympanitic
(drum-like)
sounds
produced by
percussing over
air filled
structures.
There are two basic sounds with
Percussion
Dull sounds that
occur when a solid
structure (e.g. liver)
or fluid (e.g. ascites)
lies beneath the
region being
examined.
Examination of Liver (Percussion)
Midclavicular line
is noted
Second
intercostal space
is noted
The two solid organs are
percussable in the normal patient
Liver: will be entirely
covered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
Spleen: The spleen is
smaller and is entirely
protected by the ribs.
To determine the size of the liver
Measure the liver
span by percussing
hepatic dullness from
above (lung) and
below (bowel). A
normal liver span is 6
to 12 cm in the
midclavicular line.
To determine the size of the liver
Start just below the
right breast in a line
with the middle of
the clavicle.
Percussion in this
area should
produce a relatively
resonant note.
To determine the size of the liver
Move your hand
down a few
centimeters than
you will be over
the liver, which
will produce a
duller sounding
tone.
To determine the size of the liver
Continue
downward until
the sound
changes once
again. At this
point, you will
have reached the
inferior margin of
the liver.
Examination of Liver (Percussion)
Upper margin is
noted by first dull
percussion note
Lower margin is
noted by first
tympanitic note
To determine the size of the
liver
The resonant tone produced by
percussion over the anterior chest
wall will be somewhat less drum like
then that generated over the
intestines. While they are both
caused by tapping over air filled
structures, the ribs and pectoralis
muscle tend to dampen the sound.
Examination of Spleen
(Percussion)
Percussion at Castell’s Spot
Castell’s Spot identified
Left anterior axillary line identified
Left lower costal margin identified
Percussion at Castell’s Spot while patient
inhales and exhales deeply
Dull tone indicates
possible splenomegaly
Spleen percussion
Enlarged spleen
produce a dull
tone, in the left
upper quadrant
percussion but
should then be
verified by
palpation.
Palpation
Abdominal examination
Abdominal Palpation
Technique
Light
Deep
Liver edge
Spleen tip
Kidneys
Aorta
Masses
Abdominal palpation
To palpate four
quadrants
superficially
from LLQ
counterclockwise
Light Palpation
Light Palpation
First warm your
hands by rubbing
them together before
placing them on the
patient.
Abdominal wall
depressed
approximately 1 cm
Abdominal palpation
Use pads of three
fingers of one hand
and a light, gentle,
dipping maneuver to
examine abdomen
Palpation (light)
Any areas of pain or
tenderness are
reserved for
evaluation at the end
of the exam
Light Palpation
Mostly looking for
areas of tenderness
Tenderness is a
physical exam finding
a reflex occurs
(muscle splinting,
wide eyes, moaning,
teeth gritting).
Palpation
Light palpation assesses
Muscle tone
Cutaneous
hypersensitivity
(suggests peritoneal
irritation)
Palpation
Light palpation assesses
Presence of
superficial
(intramural) masses is
more prominent if
patient raises their
head ,Intra-abdominal
mass is less
prominent if patient
raises their head
Deep Palpation
Palpation (deep)
Entire palm
Either one- or
two handed
technique is
acceptable
Deep Palpation
Use palmar surface of
fingers of one hand
(greatest number of
fingers) and a deep,
firm, gentle maneuver
to examine abdomen
Palpation
Palpate deeply with
finger pads (do not
“dig in” with finger
tips)
Deep Palpation
Palpate tender areas
last
Try to identify
abdominal masses or
areas of deep
tenderness
Two handed technique
When deep
palpation is difficult,
examiner may
want to use left
hand placed over
right hand to help
exert pressure
Palpation (deep)
Push as deeply as
patient will allow
without significant
discomfort
Normal structure that may be
palpable
Sigmoid colon
Liver
Kidney
Abdominal aorta
Iliac artery
Distended bladder
Gravid and nongravid uterus
Xyphoid process
spleen
Abdominal mass
Intra abdominal
masses or
enlargements of the
liver, gallbladder or
spleen
Abdominal wall mass
Intra abdominal masses or enlargements of
the liver, gallbladder or spleen
They will shift down
with inspiration and
back with expiration.
(not true of masses
within the abdominal
wall or retroperitoneal
structures).
Aabdominal wall mass
It will become more
evident and palpable
when patient flexes
neck as this contracts
rectus muscles.
Paraumbilical node
Abdominal pain and
Tenderness
Type of abdominal pain
Visceral pain
Somatic pain
Visceral pain
This is pain that
arises from an
organic lesion or
functional disturbance
within an abdominal
viscus (dull, poorly
localized, and difficult
for the patient to
characterize).
Somatic pain
Painful lesion of the
skin
Sharp, bright, and
well localized
Indicates
involvement of
parietal peritoneum
or the abdominal
wall itself
Tenderness
If there is tenderness
determine the point of
maximum tenderness
and its distribution
Abdominal muscle spasm
Voluntary guarding
Tensing abdominal
muscles due to
patient anxiety,
ticklishness, or
toprevent palpation to
a painful area
Involuntary guarding
Muscular spasm or
rigidity due to
peritoneal
inflammation
May be localized
(early appendicitis )or
diffuse (perforated
bowel)
Board-like rigidity
If abdominal wall is
palpated as obviously
tense, even as rigid
as a board, board-like
rigidity is so called. Is
caused by the spasm
of abdominal muscle
due to peritoneal
irritation.
Differential diagnosis of abdominal
pain
Spine pain
Abdominal wall
pain( differentiated by
having the patient
tense his abdominal
muscles, by forcefully
elevating his head
while keeping his
shoulders flat on the
table)
Liver palpation
Liver palpation
(Standard Method)
Start in the RUQ,10
centimeters below the
rib margin in the midclavicular line
Place left hand
posteriorly parallel to
and supporting 11th &
12th ribs on right.
Standard Method Liver palpation
Ask the patient to
take a deep breath.
You may feel the
edge of the liver press
against your fingers.
Liver palpation
(Standard Method)
Palpating hand is
held steady while
patient inhales
Liver palpation
(Standard Method)
Palpating hand is
lifted and moved
while the patient
breathes out
Liver palpation
Another method of
palpating the liver
uses the radial border
of the index finger. In
this method the
anterior hand is
placed flat on the
anterior abdominal
wall with fingers
parallel to the costal
margin
Alternate Method Liver palpation
Is useful when the
patient is obese or
when the examiner
is small compared
to the patient.
Alternate Method Liver palpation
Stand by the patient's
chest.
"Hook" your fingers
just below the costal
margin and press
firmly.
Hepatomegaly
More than 1cm below
the costal margin
An exception is a
congenitally large
right lobe of the liver
Severe, chronic
emphysema
Pulsation transmitted from aorta Tricuspid valve insufficiency
Hepatojugular reflux sign
If you press the liver,
you will find the
dilated jugular vein
becomes more
bulged or distended,
as from the
enlargement of liver
passive congestion
resulted from right
failure.
Ballotable sign
Spleen palpation
Spleen palpation
Seldom palpable in
normal adults.
Causes include
COPD, and deep
inspiratory descent of
the diaphragm.
Spleen palpation
Support lower left rib
cage with left hand
while patient is supine
and lift anteriorly on
the rib cage.
Spleen palpation
Palpate upwards
toward spleen with
finger tips of right
hand, starting below
left costal margin.
Have the patient take
a deep breath.
Examination of Spleen
(Palpation)
Deep technique used
Starting point is RLQ,
proceeding to LUQ
Kidney palpation
Kidney palpation
Place left hand
posteriorly just below
the right 12th rib. Lift
upwards.
Palpate deeply with
right hand on anterior
abdominal wall.
Examination of Kidney
Patient take a deep
breath.
Feel lower pole of
kidney and try to
capture it between
your hands.
Examination of Kidney
Right kidney may be felt to slip between hands
during exhalation
Palpation of the Aorta
Examination of Aorta
Flat palm placed
over the the
epigastrium to
locate pulse
Examination of Aorta
Press down deeply in
the midline above the
umbilicus.
The aortic pulsation is
easily felt on most
individuals.
Examination of Aorta
Hands then oriented
vertically on either
side of midline with
distal fingers at level
of pulsation; equal
pressure applied until
pulsation is palpated
A well defined, pulsatile mass, greater than
cm across, suggests an aortic aneurysm.
Examination of Aorta
Lateral width of pulsation is determined by
space between index fingers
Special exam
Abdominal examination
Special exam
Murphy’s Sign
McBurney’s
Point
Rovsing’s Sign
Psoas Sign
Obturator
Sign
Re bound
Tenderness
Costovertebral
tenderness
Shifting
Dullness
Fluid wave
Murphy’s Sign (acute cholecystitis)
Examiner’s hand is at
middle inferior border
of liver.
Patient is asked to
take deep inspiration.
If positive patient will
experience pain and
will stop short of full
inspiration
Hepatitis, subdiaphragmatic
abscess Cholecystitis
McBurney’s Point
Localized tenderness
Just below midpoint
of line between right
anterior iliac crest and
umbilicus.
Heel strike, riding
over bumps in road
while driving,
coughing, will
produce pain.
McBurney’s Point (Common Causes)
Appendicitis
Incarcerated or
strangulated hernia
Ovarian torsion (twisted
Fallopian tube)
Pelvic inflammatory
disease
Abdominal abscess
Hepatitis
Diverticular disease
Meckel''s diverticulum
Rovsing’s Sign
Patient will
experience right lower
quadrant pain (in
region of McBurney’s
Point) when left lower
quadrant is palpated.
Non-Classical Appendicitis
Iliopsoas Sign
Obturator Sign
Iliopsoas Sign
Patient can lay on side and extend leg at the hip
or have patient lay on back and try to flex hip
against the resistance of examiner’s hand on
thigh. If patient has an inflamed retrocecal
appendix, this will produce pain.
Iliopsoas Sign
Anatomic basis for
the psoas sign:
inflamed appendix is
in a retroperitoneal
location in contact
with the psoas
muscle, which is
stretched by this
maneuver.
Obturator Sign
Internally rotate right leg at the hip with the knee
at 90 degrees of flexion. Will produce pain if
Obturator Sign
Anatomic basis for
the obturator sign:
inflamed appendix in
the pelvis is in contact
with the obturator
internus muscle,
which is stretched by
this maneuver.
Rebound Tenderness
(For peritoneal irritation)
Warn the patient what
you are about to do.
Press deeply on the
abdomen with your hand.
After a moment, quickly
release pressure.
If it hurts more when you
release, the patient has
rebound tenderness. [4]
Cost vertebral Tenderness
(Often with renal disease)
Use the heel of your
closed fist to strike
the patient firmly
over the
costovertebral
angles.
Compare the left
and right sides.
Warn the patient Patient sit up on the exam table
Shifting Dullness
(For peritoneal fluid)
Percuss from anterior
abdomen laterally to
outline areas of
dullness noted
Examination for Shifting
Dullness
Patient rolled slightly
toward the examined
side; movement of the
dull point medially is
described as “shifting
dullness” and
suggests ascites
Shifting Dullness
Fluid wave