Abdominal examination (Physical Examination for OSCE)

General rules before the abdominal examination
1. For the examiner
 Examination is done in warm room with good light
 The examiner must warm his hands, has short finger nails and use
warm stethoscope
2. For the patient
 Patient should be lying flat (Supine)
 Abdomen should be fully exposed; from above the xiphoid
process to the symphysis pubis (the groin should be visible)
 Sheet over the genitalia
 Arms at sides or over the chest (behind head tightens abdomen)
 flexing knees may relax abdomen
 The head and the neck are supported by enough pillows

 Swelling
 Deformity
 Loin masses
 Pigmentation
 tuft of hair
Inspection of the Back

Inspection of the Anterior Abdominal Wall
Inspection of mid-line
from above downward
Inspection of the sides
1- Subcostal angle
2- Epigastric pulsation
3- Divarication of recti
4- Umbilicus
5- Suprapubic hair distribution
6- Hernial orifices
1- Contour of the abdomen
2- Collateral (dilated veins)
3- Skin
4- Scars
5- Movement with respiration
6- Visible peristalsis
N.B. we start the inspection of the abdomen by comment on contour of
the abdomen

Mid-line Inspection
1- Subcostal angle
- Normal: acute to right angle (70 – 90 °)
- Abnormal: obtuse angle; occurs in:
 abdominal causes: chronic ↑↑ in intra-abdominal
pressure (as in ascites, upper abdominal swelling)
 Chest causes: emphysema

2- Epigastric pulsation
 Aortic
- normal
- aortic incompetence
- aortic aneurysm
 Rt ventricle
- RVH in bilharzial corpulmonale
 Hepatic “pulsating” liver
- tricuspid regurge
- hemangioma

3- Divarication of recti
Bulge of linea alba between the recti muscles with their
wide separation
Causes:
 ↑↑ intra-abdominal pressure (ascites, multiple
pregnancies)

4- Umbilicus
I. Site
 normally  midway between xiphisternum and
symphysis pubis
 Pushed downwards  due to - masses in upper
abdomen - ascites
 Pushed upwards  due to masses lower abdomen
arising from the pelvis
II. Shape
 Normally  inverted
 Abnormally  everted due to increase in intra-
abdominal pressure (ascites / pregnancy)

III. Hernia
 Expansile impulse in cough
IV. Dilated veins
 Caput medusa in portal hypertension
V. Skin
 Pigmentation around umbilicus (T.B. peritonitis, Addison dis.)
 Nodules “sister Mary-Joseph nodules” (abd. malignancy)
 Ecchymosis “Cullen's sign” (hemorrhagic pancreatitis and
internal hemorrhage)
VI. Discharge:
 Pus  inflammation
 Stool  intestinal fistula
 Urine  patent urachus

5- Suprapubic hair distribution
Normally:
 In male  the hair reach the umbilicus “triangular, with
the apex towards the umbilicus”
 In female  the hair ends in horizontal line
Abnormally  feminine hair distribution in male in L.C.F.

6- Hernial orifices
Weak points in the abdomen in which the abdominal contents may pass
through it with increase intra-abdominal pressure
- Detected by: the patient is examined in standing position and asked to
cough
- Sites:
 Linea alba (epigastric)
 Umbilical
 Incisional (old scars)
 Inguinal
 Femoral
 Scrotal
N.B. Hernia= expansile impulse on cough

Inspection of Sides
1- Contour of the abdomen
- Normally  the abdomen is gently convex from side to side
and from front to back
- Abnormally 
 Retraction (scaphoid abdomen) : due to starvation,
wasting diseases or dehydration
 Bulging (distension or swelling): either generalized or
localized
N.B. The flanks should be checked for any bulging.

Scaphoid abdomenslightly full abdomen
but not distended

• examination of abdominal contours
– Standing at the foot of the table
– Lower yourself until the anterior
abdominal wall
– ask the patient to breathe
normally while you are inspect
the abdomen.

Generalized abdominal
distension
Localized abdominal
distension
1- Fluid (ascites)
2- Fat (obesity)
3- Flatus and Faeces
4- Foetus (pregnancy)
5- Full urinary bladder
1- Site
2- Shape and size
3- Pulsate on cough (hernia
or not)
4- Movement with
respiration
5- Extra-abdominal or Intra-
abdominal (by asking the pt.
to sit up in bed unsupported)
Contour of the abdomen

Generalized abdominal distension

2- Collaterals (Dilated – Tortuous – Engorged
Veins): in cases of
IVC obstruction Portal vein obstruction
1- Site of
collaterals
Laterally (Sides) Around umbilicus (caput
medusa)
2- Blood
flow
From below upwards
“towards the head”
(to bypass the
obstruction the blood
bypass the IVC via
abdominal wall veins to
the thorax)
Away from the
umbilicus”towards the legs”
(the blood pass from the left
branch of portal vein to para
umbilical vein to anterior
abdominal wall veins through
the umbilicus)
3- cause in
hepatic Pt
Functional compression
on IVC by tense ascites
Intra-hepatic causes of portal
hypertension
N.B. Dilated veins can be made more visible by asking the patient to
cough or strain, while the patient is sitting or semi-setting.

Methods of Detection
- The 2 index fingers of both hands are used to milk the blood
away from one segment of a dilated vein then, applying
firm pressure on both ends of the segment  the fingers
then can be lifted one by one, while observing the rate of
filling at which the vein fills from each direction the blood
will be seen coming more rapidly from the direction of blood
flow.
N.B. visible veins without engorgement and tortuosity may be
normal finding in thin persons, particularly when the abdominal
wall is distended, often in epigastrium

Caput medusae accentuated by marked ascites.
An extensive plexus of veins is seen radiating from the umbilical region
and radiating across the anterior abdominal wall. Note the large vein
coursing inferiorly along the right flank (arrows). This is the superficial
epigastric vein.

3- Skin of the abdominal wall
 Stretched – Smooth – Shiny  in marked distended
abdomen
 Striae (due to rapid stretch of the abdominal wall with
rupture of elastic fibers)
Striae alba “white”: in obesity, ascites, pregnancy
(striae gravidarum)
Striae rubra “red”: in cushing disease and prolonged
steroid therapy they are often larger and wider,
and may involve the face

 Scratch marks  in obstructive jaundice
 Sinus and fistula
 Pigmentation – Purpura – Petichae in LCF

It is often difficult to understand whether tiny red spots arising on skin
surface are Petechiae or Purpura. However, Petechiae spots have a very
small diameter that is maximum 3 mm in size. Purpura rashes are larger
in size. These have a diameter that is about 5 mm. A spot that is bigger
than Purpura is known as common bruise or echymosis
Echymosis
Abdominal
petichae

4- Scars
 Type (operation or cautery)
 Site (suggest the name of operation) e.g.
Rt. Hypochondrium: scar of cholecystectomy
Rt. Iliac fossa: scar of appendicectomy
Lt. Paramedian: Scar of splenectomy
 Pigmentation
 Impulse on cough (incisional hernia)
 Healing cleanly by 1st intention(thin, regular) or healed
infected by 2nd intention (wide, irregular, with keloid or
not which is hypertrophic area outside the field of
normal scarring)

5- Movement with respiration
decrease or absent movement, occurs due to:
 Rigidity (peritonitis)
 Tense ascites
 Diaphragmatic paralysis

6- Visible peristalsis
Due to
 Pyloric obstruction  in the upper abdomen (from Lt. to
Rt.)
 Small intestinal obstruction  around the umbilicus
 Large intestinal obstruction  in the upper abdomen
(from RT. to Lt.)
Stimulated by
 Gentle tapping
 Cold stimulation of the skin (2 drops of ether)

General rules for palpation
For the examiner
 Examination is done in warm room with good light
 The examiner must warm his hands, has short
finger nails and approach slowly
 use warm stethoscope
 Distract the patient with conversation or
questions

General rules for palpation
For the patient
• Patient should have an empty bladder
• Patient supine, arms at sides or folded across chest - avoid
arms above the head as this tightens the abdomen
• The abdomen is fully exposed
• Before you begin, ask the patient to point to areas of pain and
examine last
• Observe the patient face “expression” during examination
• Flexing the knees may relax the abdomen
• The head and neck are supported by enough pillows

Normally palpable structures
1. Contracted muscles of abdominal wall in muscular persons
2. Colon (caecum and sigmoid) is felt when it is spastic (full of gas or
fluid)
3. Vertebra (L4 – L5)
4. Pulsations of abdominal aorta (usually felt below the umbilicus) in
thin persons
5. Lower pole of Rt. Kidney (especially in female with thin lax
abdominal wall)
6. Liver edge descends 1-3 cm below the costal margin on deep
inspiration, but the consistency is soft and difficult to feel.

Types of Palpation
Superficial Deep

For:
- Confidence of the patient
- Superficial masses
- Tenderness
- Rigidity
- Temperature
“from the Lt. iliac fossa  in anticlockwise direction
till the suprapubic area”
Superficial Palpation

• Technique
– Use pads of three fingers (palmar surface of fingers) of
one hand and a light, gentle, dipping maneuver to
examine abdomen
– Abdominal wall depressed approximately 1 cm

Palpating the abdomen – Light palpation

Deep Palpation
For :
- Organs “liver, spleen, gall bladder, kidney, colon, urinary
bladder”
- Masses
- Areas of deep tenderness and rebound (pain induced or
increased by letting go)
Deep palpation include the following methods
- Ordinary technique “classic”
- 2 handed method
- Bimanual
- Dipping
- Hooking
- Rolling

• Technique
– Entire palm (use palmar surface of fingers of one hand; greatest
number of fingers) and a deep, firm, gentle maneuver to examine
abdomen
– Either one- or two handed technique is acceptable (When deep
palpation is difficult, examiner may want to use left hand placed
over right hand to help exert pressure)
– Palpate tender areas last
– Palpate deeply with finger pads (do not “dig in” with finger tips)
– Abdominal wall depressed around 4 cm or Push as deeply as
patient will allow without significant discomfort.

Palpating the abdomen – Deep palpation

 The spleen has the size of cupped hand
 It lies between the stomach and fundus of diaphragm
 Surface anatomy
- it lies in the epigastrium and the adjoining part of the Lt.
hypochondrium
- parallel to ribs 9, 10, 11
- its long axis parallel to the posterior part of the shaft of 10th rib
- the spleen has
 2 surfaces; diaphragmatic surface (convex, smooth);
visceral surface (concave, irregular, contain the hilum and
carries impression of 4 organs)
 2 borders; upper border (sharp, notched); lower border
(smooth, rounded)
 2 ends; medial end (broad, 4cm from the median plane);
lateral end (narrow and tappering)

Surface anatomy of the Spleen
11th rb
Medial end
Lateral
end
10th rb
9th rb
10th rb

Diaphragmatic surface
Visceral surface
Lower
border

 The spleen is not normally palpable
 It has to be enlarged 3 times its usual size to be palpable
under the subcostal margin
 The direction of enlargement is downward and towards the
Rt. Iliac fossa
 The spleen which is not felt doesn’t exclude splenomegaly
but it can be said that the spleen is not felt

Methods of Deep Palpation
 Classical method (single-handed method)
 Two handed method
 Bimanual examination
- in the supine position - in the Rt lateral position)
 Dipping method
 Hooking method

Classical method (single-handed method)

Bimanual examination in supine position

Palpating the spleen – Bimanual
palpation in supine position

Palpating the spleen – Bimanual palpation in
supine position

With the patient in the right lateral position, minimal splenic
enlargement can be detected
Palpating the spleen – Bimanual palpation in
Rt. Lateral position

Palpating the spleen – Bimanual palpation in Rt.
Lateral position

Palpating the spleen – Bimanual palpation
in Rt. Lateral position

Examining for the spleen from behind the patient, in the right
lateral position. In this case, the fingers are "hooked" over the
costal margin.
Hooking method

Nature of this palpable spleen (put a comment on):
1. Size
 Mild (just palpable to 5cm)
 Moderate (5 – 10 cm)
 Huge (more than 10 cm, below the umbilicus)
2. Border
3. Surface
4. Consistency
5. Tenderness (e.g. due to splenic infarction, septicemia,
SBE)

Applied anatomy and physiology of the spleen
 The spleen is composed predominantly of lymphoid and R.E. tissues,
so, any condition “infectious; immunologic; metabolic; malignant or
idiopathic” that causes hyperplasia of the lymphoid/RES may cause
splenomegaly
 The spleen is expansile organ containing many sinusoids, so,
interference with its venous drainage as in portal hypertension will
cause splenomegaly “congestive splenomegaly”
 The spleen destroys senile and defective RBCs, so, in hemolytic
anemias, this function is increased with splenomegaly “except in
sickle cell anemia”

Hypersplenism
- Whenever the spleen is enlarged, hypersplenism may occur
- It is characterized by
 Pancytopenia in the peripheral blood (Normocytic
normochromic anemia, neutropenia, thrombocytopenia in the
CBC) due to hyperfunction of the spleen
 One element or two may be decreased only
 B.M examination: hypercellular or normal
 Splenectomy returns the CBC to normal

Characters of splenic swelling to be differentiated
from the Lt. kidney
- By inspection  Moves with respiration down and medially
- By palpation  it has a notch on the lower part of the anterior
(upper) border “PATHOGNOMONIC”
hand can't be insinuated between the mass and the
costal margin to get above its upper pole
 negative ballottement (can’t be pushed in the renal
angle)
- By percussion  dull on percussion and continuous with the splenic
dullness

Upper border is marked by joining the following points:
1st point Lt. 5th intercostal space in the MCL “apex of the heart”
2nd point Xiphisternal joint.
3rd point Upper border of 5th rib in Rt. MCL
4th point 7th rib at RT MAL.
5th point  9th rib at RT scapular line.
Lower border is marked by curved line joining the following points:
1st point Lt. 5th intercostal space in the MCL “apex of the heart”
2nd point  8th costal cartilage in the Lt. parasternal line.
3rd point midway between xiphisternal junction and the umbilicus
4th point  9th costal cartilage in the Rt. MCL.
5th point  10th rib in the Rt. MAL.
6th point  12th rib in Rt. Scapular line

Xiphisternal junction
Rt. 5th rib
Rt. 7th rib
Rt. 9th rib
LT. 5th space
11
2 2
33
4 4
5 5
6
77
6
9
8
10
8
9
10
umbilicus

Rt. 9th costal
cartilage
LT. 5th space
11
2 2
33
4 4
5 5
6
77
6
9
8
10
8
9
10
LT. 8th costal
cartilage
Midway
between
umbilicus
&xiphisternum
umbilicus
Rt. 10th rib

Technique of detecting the liver
 Upper border is detected by heavy percussion “hepatic
dullness”
 Lower border is detected by deep palpation and light
percussion
After palpation of the lower border of the liver, you must
comment on
I. Liver span : Distance between the upper and lower
borders of the liver; which is
4 – 8 cm in the middle line “represents the Lt.
lobe”
9 – 14 cm in the Rt. MCL “represents the RT.
lobe”

II. Nature of this palpable liver (put a comment on):
1. Size “in finger breadth or cm”
 Normally: not felt below the costal margin
 Abnormally: enlarged “causes of hepatomegaly” or shrunken
“liver cirrhosis and fibrosis”
2. Surface
 Normally: smooth
 Abnormally:
- smooth “congestion, inflammation, infiltration”
- fine irregular “cirrhosis”
- nodular “malignancy”
2. Edge
 Normally: sharp
 Abnormally:
- sharp “cirrhosis, fibrosis”
- rounded “congestion, inflammation, infiltration”

4. Consistency
 Normally: soft
 Abnormally:
- soft “congestion, inflammation, infiltration”
- firm “cirrhosis, fibrosis”
- hard “malignancy”
5. Tenderness: congestion, inflammation, infiltration, malignancy
6. Pulsation: TI, TS, hemangioma

Methods of Palpation
 Classical method (single-handed palpation)
 Two-handed method
 Bimanual examination
 Dipping method
 Hooking method
- Single-handed palpation is used for lean individuals, while the
bimanual technique is best for obese or muscular individuals. Using
either technique, the liver is felt best at deep inspiration.

Single-handed
method
- For single-handed palpation, the examiner's right hand is initially placed on the
patient's abdomen in the right lower quadrant and parallel to the rectus muscle in
the MCL. This is done so that palpation of the rectus is not confused with palpation
of the underlying and adjacent liver
- Gently pressing in and up, ask the patient to take a deep breath.
 Palpating hand is held steady while patient inhales
 Palpating hand is lifted and moved while the patient breathes out
 If the liver is enlarged, it will come downward to meet your fingertips and will
be recognizable.

 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

the left hand is held posteriorly,
between the 12th rib and the iliac crest.
It is lifted gently upward to elevate the
bulk of the liver into a more easily
accessible position, while the right
hand is held anterior and lateral to the
rectus musculature. The right hand
moves upward using gentle, steady
pressure until the liver edge is felt.
Bimanual palpation
of Liver

– Is useful when the
patient is obese or
when the examiner is
small compared to the
patient.
– Stand by the patient's
chest.
– "Hook" your fingers
just below the costal
margin and press
firmly.
Hooking method

Causes of ptosed liver
 Emphysema
 Pneumothorax
 Pleural effusion
 Subphrenic abscess
Causes of upward displacement of the liver
 Lung fibrosis/collapse
 Diaphragmatic paralysis
 Ascites / abdominal tumours

Percussion
Percussion is a method of tapping on a surface to determine the
underlying structure

Technique
- It is done with the middle finger of Rt. hand (plexor) tapping on DIP
of the middle finger of the Lt. hand (pleximeter) using a wrist action.
- The non striking finger (pleximeter) is placed firmly on the abdomen,
remainder of hand not touching the abdomen.
- Remember that it is easier to hear the change from resonance to
dullness – so proceed with percussion from areas of resonance to
areas of dullness.
pleximeter
plexor

Percussion of the abdomen
- The abdomen gives a resonant note which varies according to the
amount of gas present in the intestine
- Type of percussion: Light percussion
- Values:
 Deleneation of borders of abdominal organs (& assessing for
organomegaly).
 Detection of ascites
 Detection of gaseous distension “tympanic resonant note”
 Detection of acute abdomen (obliteration of normal liver
dullness) in;
- Perforated peptic ulcer and colon
- Subphrenic abscess with gas forming organisms

Percussion “liver”
Upper border  by deep percussion
Lower border  by light percussion
Upper border
 Define the sternal angle “angle of Louis” (2nd rib), then start
percussing the 2nd intercostal space in the Rt. MCL (Start just
below the Rt. breast in RT. MCL). Percussion in this area should
produce a relatively resonant note
 Percussing in the chest moving down towards the abdomen about
½ to 1 cm at a time (in the intercostal spaces).
 Note where the percussion notes change from resonant to dull.
 The normal hepatic dullness will be reached at the 5th intercostal
space in the RT. MCL
Lower border
 Begin percussion below the umbilicus, in the Rt. MCL and proceed
upward until dullness is encounter.

Percussion “spleen”
- Percussion of Traube’s area
- Splenic percussion sign “Castell’s method”
- Nixon’s method

Traube's area
 It is a semilunar (crescent)-shaped area
 It is area of tympanic resonance overlying the fundus of stomach
 Boundaries
Upper border lower border of Lt. lung (convex line from the Lt.
6th rib in MCL to the Lt 9th rib in mid-axillary line)
Right border Lateral margin of left lobe of liver (from Lt. 6th rib
in MCL to the Lt. 8th costal cartilage)
Left border anterior border of the spleen (Lt. 9-11 spaces in
mid-axillary line)
Lower border Lt. costal margin (from the Lt. 8th costal cartilage
to Lt. 11th space in mid-axilary line )

 Causes of dullness of Traube’s area:
1. Full stomach/ gastric tumours.
2. Left sided Pleural effusion / pericardial effusion “from above”.
3. Ascites/abdominal tumour “from below”
4. Splenomegaly “from left side”.
5. Enlargement of left lobe of liver “from the right side”.

Castell’s method “Splenic percussion sign”
 Put the patient in the supine position
 Left anterior axillary line identified
 Left lower costal margin identified
 Percuss in the lowest Left intercostal space in the anterior axillary line
(usually the 8th or 9th IC space) while patient inhales and exhales
deeply
 This space should remain resonant during full inspiration
 Dullness on full inspiration indicates possible splenic enlargement (a
positive Castell’s sign)

Nixon’s method
 Place the patient in Right lateral decubitus
 Begin percussion midway along the Left costal margin
 Proceed in a line perpendicular to the Left costal margin
 Upper limit of dullness : 8 cm

Detection of Ascites
Ascites is free collection of fluid within the peritoneal cavity.
The classical signs of ascites include; abdominal distension, shifting
dullness, fluid thrill.
 Minimal ascites  detected in the knee elbow position
 Moderate ascites  detected by the bilateral shifting dullness
 Tense ascites  detected by transmitted fluid thrill “fluid wave”

Bilateral shifting dullness
1.The patient is examined in the supine position.
2.Percussion is done over the abdomen, from the umbilicus to one flank.
3.The spot of the transition from tympany to dullness is detected.
4.The patient is then turned to the opposite side, while the examiner keeps his
hand unmoved.
5. Percussion of the same spot (which is top now) gives a tympanic note.
Note: The tympany over the umbilicus occurs in ascites because bowel floats
to the top of the abdominal fluid.
air
air
fluid
fluid

Transmitted fluid thrill
Pathognomonic for ascites when the amount of fluid is large
1.The patient is examined in the supine position.
2.The patient or an assistant places one hand in the midline and presses
firmly with the ulnar border of the hand , so cut off any vibrations
transmitted by the abdominal wall.
3. The examiner places one palm on one flank, while giving a sharp tap
with the finger tips on the opposite flank.
4. Positive test: a definite wave “impulse” will be distinctly felt by the
receiving hand.

Auscultaion
• Diaphragm of stethoscope used
• Skin depressed to approximately 1 cm
• Listening in one spot is usually sufficient
• Listening for 15-20 or 30-60 seconds

Values of auscultation
1. To hear intestinal sounds  characteristic gurgling bubbling (gas
and fluid in intestine) sounds.
 Increase in: acute diarrhea (↑motility) and in early intestinal
obstruction
 Absent in: paralytic ileus
N.B. Bowel sounds cannot be said to be absent unless they are
not heard after listening for 3-5 minutes.

2. To hear vascular sounds
Arterial bruit Venous hum
(Wind at sea shore)
Systolic murmur Systolic and diastolic sound in the
epigastrium, and Lt. hypochondrial
region “Kenawy sign”
Occurs in cases of
- Abdominal aortic
aneurysm
- Renal artery stenosis
- Over very vascular tumour
“e.g. hemangioma”
Occurs in cases of
- portal hypertension due to porto-
systemic anastomosis (collateral)

3. Friction rub 
a dry, grating sound heard with a stethoscope during auscultation; may
be heared over enlarged liver or spleen
 Splenic rub: in Lt. hypochondrium; due to splenic infarction and
perisplenitis
 Hepatic rub: in Rt. Hypochondrium; due to hepatic malignancy
with perihepatitis (inflammatory changes or infection in or
adjacent to the liver).
N.B. A hepatic rub and bruit in the same patient usually indicates
cancer in the liver. A hepatic rub, bruit, and abdominal venous hum
would suggest that a patient with cirrhosis had developed a
hepatoma.

4. To detect minimal ascites (Puddle’s sign)
It is useful for detecting small amounts of ascites (as small as 120 mL;
shifting dullness and bulging flanks typically require 500 mL).
The steps are outlined as follows:
 Patient lies prone for 5 minutes
 Patient then rises onto elbows and knees
 Apply stethoscope diaphragm to most dependent part of the abdomen
 Examiner repeatedly flicks near flank with finger.
 Continue to flick at same spot on abdomen
 Move stethoscope across abdomen away from examiner
 Sound loudness increases at farther edge of puddle

5. Succusion splash  in case of pyloric obstruction (distended stomach
with gas and fluid)
 placing the stethoscope over the upper abdomen  rocking the
patient back and forth at the hips  Retained gastric material >3
hours after a meal will generate a splash sound.
6. To detect pregnancy  fetal heart sounds.

Abdominal examination (Physical Examination for OSCE)

Abdominal examination (Physical Examination for OSCE)

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