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1. PHYSICAL ASSESSMENT
OF THE ABDOMEN
Prepared By: Mr. Shaier Khan
Modified by :Samina Farooqi
BScN, UHS Lahore,
MScN, University of Health Sciences,
Lahore

2. Overview of abdominal structure and
functions
 The abdomen is a large oval cavity
 Extends from diaphragm to symphysis pubic
 Abdominal wall muscles
 Viscera: solid and hollow
 Vascular structures
FUNCTIONS
 Digestion, urination, coughing, sneezing,
defecation, childbirth etc

3.  Four quadrants
 Nine sections
 Bony landmarks
 Muscles
Landmarks for the abdominal
examination

4. Xiphoid Process
Costal Margin
Linea Alba
Anterior Superior
Iliac Spine
Symphysis Pubis
Rectus Abdominis
Inguinal Ligament

6. 9 Regions

7. Health History
 Introduction and orientation; name, role and consent
 Gastrointestinal Disorders
 Indigestion, Nausea & Vomiting, Anorexia, Hematemesis
 Ask the patient “how is your appetite”?
History of Heartburn ----sense of burning or warmth that
is retrosternal and may radiate to the neck
Excessive gas: frequent belching, distention or flatulence,
Abdominal fullness.
Dysphagia & odynophagia (painful swallowing in the
oropharynx or esophagus.
Change in bowel function
Constipation or diarrhea
Jaundice

8. Health History Cont…
Abdominal pain COLDSPAA
o Visceral: Occur throughout the abdomen, burning,
aching (throbbing), difficult to localize, varies
in quality e.g. pain in RUQ from liver
distention.
o Parietal pain: Pain in the parietal peritoneum that is
caused by inflammation, is steady, more
sever, localized, increased by movement
or coughing.
o Referred pain: Felt at more distant site, well localized.

9. Health History Cont…
 Bowel Habits
 Past Abdominal History
 Smoking History
 Medications
o Aspirin
o Other NSAIDS
 Nutritional Assessment
 24 hour recall
 Nutritional patterns
 Weight changes
 Exercise patterns

10. Urinary Tract Disorders
 Ask about
Dysuria
Nocturia, How often?
Urine passed at a time?---polyuria
Problem in holding urine?---incontinence
Any change in urine color?---hematuria
Kidney or flank pain
Urethral pain
Health History Cont…

12. Assessment Techniques
Inspection
General inspection;
 General appearance –color (jaundice), obvious pain, SOB.
Examination of the hands
 Clubbing (liver cirrhosis, IBD – Crohn’s/Ulcerative Colitis,
coeliac’s disease – malabsorption, GI lymphoma).
 Anemia (check palmar crease for color).
 Palmar Erythema (mottled (spotted), bright-red cutaneous
vasodilatation over thenar & hypothenar eminences, often
normal, suggestive of liver dysfunction).
 Leuconychia (white discoloration of the nail plate, seen in
hypo-albuminaemia, chronic liver disease).

13. Assessment Techniques
 Asterixis (flapping tremor of hepatic encephalopathy that is
characterized by jerky, irregular flexion-extension movements
at the wrist & metacarpophalangeal joints, often accompanied
by lateral movements of the fingers).
 Examination of the head & neck;
 Cushing’s syndrome; Moon face
 Nephrotic syndrome; Peri-orbital puffiness or edema, dullness,
lassitude (lethargy).
 Renal failure; Grayish pallor.
 Examine eyes for anemia (bottom eyelid) and Jaundice (sclera
– hemolysis/liver disease).

14. Assessment Techniques
 Mouth; (remove dentures, use a torch and wooden
tongue depressor).
Cracked lips; suggestive of vitamin deficiency.
Gums; spongy, bleeding and pigmentation.
Ulceration; Crohn’s disease.
Central cyanosis; (check dorsum of the tongue).

15. Inspection of Abdomen
 Contour
 Normally range from flat to rounded
 Abnormalities include scaphoid, protuberant, bulge in flanks
 Symmetry
 Abnormalities: bulges, masses, Hernia (protrusion of the
abdominal viscera through abnormal opening in muscle wall)
 Pulsation or movements (peristalsis)
 Normally: aortic pulsation and peristalsis movements may
be seen in thin persons.
 Abnormalities:
• Increased pulsation ----- aortic aneurysm
• Increased peristalsis ----- intestinal obstruction

17.  Scars (describe them, or diagram location)
 Striae (pink- purple with Cushing's syndrome)
 Spider naevi (telangiectases that consist of a large arteriole
from which radiate numerous small vessels – occur with
portal hypertension or liver disease only – more than two is
abnormal).
 Prominent dilated veins with portal hypertension, liver
cirrhosis, or inferior vena cava obstruction
 Ascites (bulging flanks).
 Caput medusa (dilated collateral veins radiating from the
umbilicus as a result of cirrhosis & portal hypertension)
 Gynaecomastia (growth of breast tissues in males – high levels of
circulating estrogen – drug-induced or chronic liver disease).
Inspection of Abdomen

18. Inspection of Abdomen
 Umbilicus
Contour, location, any inflammation
or bulge.
Abnormalities: Everted, Sunken,
Enlarged, Bluish color
 Distention:
 Definition: Unusual stretching of
abdominal wall
 Note portion of abdomen that is
distended
 Reasons for distention: obesity, flatus
(gas), feces, fluid, pregnancy or tumor Spider nevus

19. Inspection
 Causes of distension
 5 F
 Fetus
 Feces / flatus
 Fibroid
 Fat
 Fluid
 5SMP3
 Scars
 Striae
 Shape
 Symmetry
 Spider naevi
 Masses
 Pulsation
 Prominent veins
 peristalsis

20. Inspection
 Cullen's sign is superficial edema
and bruising in the subcutaneous fatty tissue
around the umbilicus.
 Grey Turner's sign refers to bruising of the
flanks, The bruising appears as a blue
discoloration, and is a sign of retroperitoneal
hemorrhage, or bleeding behind the
peritoneum

22. Auscultation
 Always done before percussion and palpation
 Use diaphragm of stethoscope
 Start with RLQ, auscultate in all 4 quadrants.
 In auscultation for bowel sound, note frequency and
characteristics:
 Normally: high pitched, gurgling, clicks, flowing sound, irregular,
5-35/min.
 Hyper active: loud, high-pitch, rushing, due to hyper-motility of
peristalsis
 Hypoactive or absent: following abdominal Surgery; listen for five
minutes before deciding a completely silent
abdomen.

23. Additional Sounds
In hypertensive patient, always listen for;
 Bruits:
o Bruits are low pitched, vascular sounds, resembling
murmurs, caused by partially obstructed artery or
turbulence of blood flow.
o Listen in epigastrium and each upper quadrant
o Listen in costo-vertebral angle (with patient seated)
o Listen over aorta, iliac arteries, femoral arteries

24. More on Auscultation

25. PERCUSSION
 Assessment technique in which gently tapping on
the skin is used to create a vibration.
 It is used to:
 Assess size and density of the organs in the abdomen
 Detect fluid, gaseous distention and abnormal masses
 Tympany-gas (dominant sound because of air in small
intestine)
 Dullness-solid masses/organs, due to feces or fluid and
distended bladder.

26. PERCUSSION
 Percuss in all the 4
quadrants
 Note tympani over
gas filled, and
 Dullness over fluid
filled tissue

27. Percussion of the Liver
 To percuss the liver or estimate its size in right mid-
clavicular line, start below the umbilicus with
tympani and percuss upward toward liver dullness.
Mark to indicate the lower liver border.
 Now percuss in the right mid-clavicular line, from
lung resonance down to liver dullness. This indicates
the upper border of the liver.
 Mark this and measure between the two lines. This is
the height of the liver.
 Normal liver span ranges from 6-12cm at Right MCL
and 4-6cm at MSL. Increase liver span is due to liver
enlargement.

28. Careful consideration must be taken when percussing patients
with emphysema, ascites, pregnancy, or colon gas distension.
Dullness may be pushed up in these conditions.
4.6 cm
6-12 cm

29. Assessing for Ascites
 Shifting dullness
With patient lying supine, percuss from the
center of abdomen, lateral into the flank until
a dull note is obtained. Mark this level.
Roll the patient onto the other side (opposite
from that percussed) and pause for at least 10
seconds.
Ascites is suggested if note becomes tympanic
and confirmed by obtaining a dull note while
percussing back towards the umbilicus.

30. Assessing for Ascites
Shifting Dullness

31. Test for Fluid Wave or Fluid Thrill
 Place hand on patient’s flank, flick the skin of the patient’s
abdominal wall over the other flank (using thumb or forefinger).
 If a fluid thrill or impulse is felt, repeat
the procedure with patient’s hand
placed along midline of the abdomen
to reduce any possible thrill transmitted
through the abdominal wall.
 Easily palpable impulse suggest
ascites.
 Succussion splash: elicited by placing the
hands over the lower ribs and shaking
the patient quickly and rhythmically
from side-to-side.
Fluid Wave

32. Percussing the Spleen
 Spleen is located in the curve of the diaphragm just
posterior to the left mid-axillary line.
 When the spleen enlarges, it does so anteriorly,
downward & medially.
 This will replace the tympani of the stomach & colon
with dullness.
 Method
 Percuss in the lowest interspace in the left anterior
axillary line for tympani.
 Ask the patient to take a deep breath and percuss on
inspiration. The percussion note should remain tympanic.
 A change to dullness suggest splenomegaly.

33. PALPATION
 Palpation is used to assess muscle tone, tenderness,
size & location of organs, presence of fluid and any
abnormal masses. Palpation may be light or deep.
Light Palpation
 Do not drag fingers, lift them instead.
 Normally: voluntary muscle guarding occurs when patient
feels cold or is sensitive especially during exhalation.
 Abnormally: Involuntary rigidity i.e. a constant board like
hardness of muscles not relieved with exhalation; occurs
due to acute pain such as in peritonitis.
 Check for rigidity, large masses and tenderness.

34. PALPATION
Deep Palpation
Use flat of hand (avoid fingertips – as it induces
muscular resistance; start away from the site of
tenderness).
Push down about 5-8 cm clockwise
Feel for any mass and look for its location, size,
shape, consistency, tenderness, pulsations,
mobility with respiration or with examining hand.
Feel for any organo-megally if present.

35. PALPATION
If patient is obese or with thick rigid skin, use
two hands to palpate. Place one on top of
other and feel with lower hand.
Normally, mild tenderness may occur when
palpating sigmoid colon. Other than that no
tenderness should be felt.

36. Deep Palpation
Light Palpation

37. PALPATION
 Assess for peritoneal inflammation
 Ask the patient to cough, determine where the cough
produce pain.
 Palpate gently with one finger to map area of tenderness
 Look for rebound tenderness
 Watch and listen to the patient for signs of pain
 Press finger in, firmly and slowly then quickly withdraw.
 Rebound tenderness means fingers withdrawal has
caused the pain---not the pressure and this indicates
peritonitis that is peritoneal inflammation.
 Check for Psoas sign and Obturator sign

38. PALPATION OF THE LIVER
 Liver is palpated in order to evaluate its surface,
consistency, and tenderness.
 Method
With patient lying supine, place your left hand
behind the patient to support 11th & 12th ribs.
Place the fingertips of your right hand anteriorly,
under the rib cage press in and up.
Ask patient to take deep breath, if palpable, try to
feel the edge of the liver, note any tenderness.
Normal liver edge if palpable is soft, sharp, regular
and smooth.

39. PALPATION OF THE LIVER
 Hooking technique
It is used to palpate the liver especially when
the patient is obese.
Stand to the right of the patient’s chest
Place both hands side by side
Press in with your fingers and up toward the
costal margin.
Ask the patient to take deep breath
Feel the liver edge

40. PALPATION OF THE LIVER
Hooking technique

41. PALPATION OF THE LIVER
 Assessing tenderness of the liver
Place your left hand flat on the lower right rib
cage and then strike your hand with the ulnar
surface of your right fist.
Ask the patient to compare the sensation with
that produced by similar strike on the left side.
Tenderness over the liver suggest inflammation.

42. PALPATION OF GALL BLADDER
Hook your fingers or thumb of your right hand
under the costal margin
Ask the patient to take a deep breath.
If the patient is unable to continue breathing
due to pain indicate positive Murphy's sign.
This may suggest acute cholecystitis .

43. Palpating the Spleen
The spleen is usually not palpable.
Percussion of the spleen can’t confirm splenomegaly, it
is confirmed by palpation.
From patient’s right side, reach over and around under
patient with your left hand.
Place right hand below left costal margin and press in
towards the spleen.
Ask the patient to take deep breath. At the height of
inspiration, release the pressure on the examining hand.
At this point, the fingertips will slip over the lower pole
of the spleen when significantly enlarged. Note any
tenderness

44. Palpating the Spleen
 If the spleen is not palpable, move the examining
hand upwards after each inspiration until the
fingertips are under the costal margin.
 Repeat this process along the entire rib margin as
the position of the enlarging splenic tip is variable.
 If still not palpable, position the patient in the
right lateral position with the left hip and knee
flexed and repeat examination.

45. Palpation of the Left Kidney
 From the patient’s left side, place your right hand
behind the patient (below and parallel to the 12th rib,
try to bring the left kidney anteriorly, place left hand in
the LUQ.
 Ask patient to take deep breath. At peak of inspiration
press your left hand firmly and deeply into the LUQ,
below the costal margin. Try to capture the kidney.
 Then ask patient to exhale & stop breathing for a while.
Slowly release the pressure of your left hand, now feel
for the kidney to slide back. If it is palpable describe its
size, contour, tenderness.
 Normal left kidney is rarely palpable.

46. Palpation of the Right Kidney
Return to the patient right side.
Place your left hand under the
patient’s back, try to displace
the kidney anteriorly.
Place your right hand at the
RUQ under the costal angle.
Now proceed as examining the
left kidney.
Normal right kidney may be
palpable, especially in thin, well
relaxed individual.

47. Assessing for Kidney Tenderness
 Find the costo-vertebral angle.
 This is the angle formed by the
lower border of 12th rib and the
transverse processes of the
upper lumbar vertebrae.
 Place left hand flat in this area
on one side, hit the hand sharply
with the fist of the other.
 Patient will admit to tenderness
if it is present, that may suggest
pyelonephritis.

48. The Urinary Bladder
 Bladder percussion is unnecessary unless there is
a suspicion of urinary retention.
 It is not palpable unless it is distended above
symphysis pubis, so palpate above the symphysis.
 By palpation, distended bladder feels smooth and
round.
 Check for tenderness
 An empty bladder is not palpable

49. Assessing the Aorta
Press firmly deep in upper abdomen slightly
to left of midline.
Feel for aortic pulsations, using your index
and thumb.
In people >50 years, assess the width of the
aorta by placing one hand on each side of the
aorta.
Normal aortic pulsation is not more than 3cm
(average 2.5cm).
Expansion of aortic pulsation suggests aortic
aneurysm

50. Assessing the Aorta
2.5 – 3 cm

51. Ask the patient to point where the pain began and where
it is now, then ask him to cough, ask if the pain increases
with coughing. Search an area of local tenderness.
Tenderness in RLQ suggests appendicitis.
Rovsing’s sign: Pain in the RLQ during left sided pressure
---indicates appendicitis.
Referred rebound tenderness: Pain in the RLQ on quick
withdrawal during left side pressure.
Assessing for Appendicitis

52. Psoas sign: Place your hand above the patient’s right
knee, ask the patient to raise his thigh against your
hand. Normally no pain should occur.
Obturator sign: Flex patient’s right thigh at the hip,
with knee bent, then rotate the leg internally at the hip.
Normally no pain should occur.
Coetaneous hyperesthesia: Gently pick up a fold of
skin between your thumb and index finger. Normally no
pain should occur.
Assessing for Appendicitis

53. Psoas Sign
Obturator Sign
A negative (Normal)
Test is No Pain

54. Examination of Hernial Orifices
 Inspect inguinal & femoral region upon patient
standing.
 Ask patient to cough (again observing).
 Invaginate the scrotum with your little finger
and gently palpate the external inguinal ring
and posterior wall of inguinal canal for possible
muscular defects.
 Feel for impulse on coughing – if hernia is
present, determine if reducible by massage.

55. Examination of the Anus and
Rectum
 General Principles
Anal canal is outlet of GI tract, 3.8cm long
It merges with rectal mucosa at the ano-rectal
junction.
Sensory nerves in anal area are responsible for
pain due to trauma.

56. Sphincters
 Two concentric layers of muscle that keep anal
canal closed.
 Internal sphincter
 Under involuntary control by autonomic nervous
system
 External sphincter

Surround internal sphincters
Under voluntary control

57. Hemorrhoids
 With increased venous pressure (portal HTN), vein
can enlarge, this is called a hemorrhoid or a varicosity.
 External hemorrhoids occur below the ano-rectal
junction. They;
 itch and bleed with defecation
 are painful and swollen with thrombosis
 resolve 7 leave flabby (loose) skin top around anal opening.
 Internal hemorrhoids originate above ano-rectal
junction
 covered with mucosa
 may appear as red mass with pressure (valsalva)