Clinical Examinations of the Abdomen

1. Clinical Examination of the Abdomen
Sreenu Thalla
Assistant Professor
Department of Pharmacology

2. Abdominal Exam
• 4 Eléments
 Observation
 Auscultation
 Percussion
 Palpation
• Pelvic, male genital &
male/female rectal exams
• All critical parts of Abdomen
exam Covered later in the year

3. Surface Anatomy

4. Assessment of the Abdomen
History of present health concern
Abdominal Pain
• Are you experiencing abdominal pain?
• How would you describe the pain? How bad is the pain (severity) on a scale of 1 to 10, with 10
being the worst?
• How did (does) the pain begin?
• Where is the pain located? Does it move or has it changed from the original location?
• When does the pain (timing and relation to particular events)?
• What seems to bring on the pain (precipitating factors) make it worse (exacerbating factors), or
make it better (alleviating factors)?
• Is the pain associated with any other symptoms such as nausea,
vomiting, diarrhoea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes or
skin?

5. Indigestion
• Do you experience indigestion? Describe.
• Does anything, in particular, seem to cause or aggravate this condition?
Nausea and Vomiting
• Do you experience nausea? Describe.
• Is it triggered by any particular activities, events, or other factors?
• Have you been vomiting? Describe the vomitus.
• Is it associated with any particular trigger factors?
Appetite
• Have you noticed a change in your appetite?
• Has this change affected how much you eat or your normal weight?

6. Bowel Elimination
• Have you experienced a change in bowel elimination patterns? Describe.
• Do you have constipation? Describe. Do you have any accompanying symptoms?
• Have you experienced diarrhoea? Describe. Do you have any accompanying symptoms?
• Have you experienced any yellowing of your skin or whites of your eyes, itchy skin, dark
urine, or clay-coloured stools?

7. Past health history
• Have you ever had any of the following gastrointestinal disorders: ulcers, gastroesophageal
reflux, inflammatory or obstructive bowel disease, pancreatitis, gallbladder or liver disease,
diverticulosis, or appendicitis?
• Have you had any urinary tract diseases such as infections, kidney disease or nephritis, or
kidney stones?
• Have you ever had viral hepatitis? Have you ever been exposed to viral hepatitis?

8. Family history
• Is there a history of any of the
following diseases or disorders in
your family
 Colon cancer
 Stomach cancer
 Pancreatic cancer
 Liver cancer
 Kidney or bladder cancer
 Liver disease
 Gallbladder disease
 Kidney disease?

9. Lifestyle and health practices
• Do you drink alcohol? How much? How often?
• What types of foods and how much food do you typically consume each day?
• How much caffeine do you think you consume each day?
• How much and how often do you exercise? Describe your activities during the day.
• What kind of stress do you have in your life? How does it affect your eating or elimination
habits?
• If you have a gastrointestinal disorder, how does it affect your lifestyle, and how do you feel
about yourself?

10. Observation & Draping
Exposure
• Drape for success – expose what you need to see!
• Use sheet to cover lower half of body
• Good lighting, warm room, table flat, hand sat side, head resting on table
• ± Feet flat on table
Make note of
• General shape
• Contours
• Symmetry
• Colour & scars
• Easiest to make observations from foot of bed.
• Examine from right side

11. Examples of Abnormal Findings on Observation
Umbilical Hernia
(Right with
Valsalva)
Obese Ascites (fluid), Yellow Enlarged gall bladder

13. Inspection
Observe the coloration of the skin
• Abdominal skin may be paler than the general skin tone because this skin is so seldom
exposed to the elements.

14. Note the vascularity of the abdominal skin
• Scattered fine veins may be visible.

15. Note any striae
• Old, silvery, white striae or stretch marks from past pregnancies or weight gain are normal.

16. Assess abdominal symmetry
• Look at the client’s abdomen as she lies in a relaxed supine position.

17. Inspect for scars
• Ask about the source of a scar, and use a centimetre ruler to measure the scar’s length.
• Document the location by quadrant and reference lines, shape, length, and specific
characteristics.

18. Assess for lesions and rashes
• The abdomen is free of lesions or rashes.
• Flat or raised brown moles, however, are normal and may be apparent.

19. Inspect the umbilicus
• Note the colour of the umbilical area.
• Observe the umbilical location.
• Assess the contour of the umbilicus.

20. Inspect abdominal contour
• Look across the abdomen at eye level from the client’s side from behind the client’s head, and
from the foot of the bed.
• Measure abdominal girth as indicated.

21. Inspect abdominal movement when the client breathes
• Abdominal respiratory movement may be seen, especially in male clients.

22. Observe aortic pulsations
• A slight pulsation of the abdominal aorta, which is visible in the epigastrium, extends full
length in thin people.

23. Observe for peristaltic waves
• Normally peristaltic waves are not seen, although they may be visible in very thin people as
slight ripples on the abdominal wall.

24. Auscultation
Auscultate for bowel sounds
• Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the
client’s abdomen.

25. Auscultate for vascular sounds
• Use the bell of the stethoscope to listen for bruits over the abdominal aorta and renal, iliac,
and femoral arteries.

26. Auscultate for a friction rub over the liver and spleen
• Listen over the right and left lower rib cage with the diaphragm of the stethoscope.

27. • Normal intestinal propulsion of food (peristalsis) generates noise (Borborygmi)
• Listen (diaphragm of stethoscope) x 15-20 seconds in 4 quadrants
• Pay attention to presence, quantity (normal ~ 2-5 seconds) & quality of sounds

28. Clinical utility
Intestinal Obstruction
• Increased frequency early (“rushes’)
• Declines in quantity, increase pitch (“tinkles”)
• Stop
After handled (surgery)
• No function or noise (ileus)
• With normal recovery, noise returns
Infection of mucosa (gastroenteritis)
• Increasedfrequency
• No findings pathognomonic
• Auscultation not helpful in otherwise normal exam
• Clinical context most important

29. Bruits
• Sounds of turbulent arterial flow –
atherosclerosis
Relevant if
• Unexplained hypertension, kidney disease,
ischemic symptoms and risk factors
Listen over
Renal arteries
• Several cm above umbilicus, either side rectus)
Central abdomen
• Celiac, SMA, IMA
Iliac arteries
• Below umbilicus

30. Percussion
Percuss for tone
• Lightly and systematically percuss all quadrants.
Percuss the span or height of the liver by determining its lower and upper borders
• To assess the lower border, begin in the RLQ at the mid-clavicular line and press upward.
• Note the change from tympany to dullness.
• To assess the upper border, percuss over the upper right chest at the MCL and percuss
downward, noting the change from lung resonance to liver dullness.
Percuss the spleen
• Begin posterior to the left mid-axillary line (MAL), and percuss downward, noting the change
from lung resonance to splenic dullness.
Perform blunt percussion on the liver
• Percuss the liver by placing your left hand flat against the lower right ribcage.
• Use the ulnar side of your right fist to strike your left hand.

31. Percussion
• Same principle as Lung
• Tapping over solid or liquid filled structure
Percussion – what’s beneath?
• skin & bones – eg: liver
• dull air filled stomach
• tympanitic
• Abdomen not designed
• Key solid structures protected
 Liver & spleen by ribs
 pancreas & kidneys in retro-peritoneum
 bladder & uterus in pelvis
• Central abdomen filled with intestines – freely moving & promotes peristalsis, tolerates direct
trauma

32. Percussion Technique
• Stand on Right
• Middle finger of non-percussing hand firmly against abdomen
• Using floppy wrist action, hammer middle finger of other hand down, aiming for last joint
• Percuss all 4 quadrants–normal =‘s mix of dull and tympanitic

33. Liver span (6-12 cm
• Startin chest, below nipple (mid-clavicular line) & move down–tone changes from
resonant (lung) to dull (liver) to resonant (intestines)
Spleen
• Small, located in hollow of ribs – percussion over last intercostal space, anterior axillary
line should normally be resonant–dullness suggests splenomegaly
Stomach – tympanitic

34. Percussion to Detect Ascites : Flank Dullness and Shifting Dullness
• Used to detect large amounts of pathological fluid (ascites)
• Intestines will float to surface
• Percussion can detect air-fluid interface
Flank Dullness alone
• Sensitivity: 84%
• Specificity: 59%
Shifting Dullness
• Sensitivity: 77%
• Specificity: 72%
“Intestines”
“Ascites”

36. Palpation
• Most important structures aren’t palpable
• Warm your hands
• Generally right hand used (left placed on top or @ your side)
• Palpate using pads & edges of middle 3 fingers
• Gentle pressure, no sudden movements
• Think about what “lives” in area you’re examining

37. Palpation
Perform light palpation
• Using the fingertips, begin palpation in a non-tender quadrant, and compress to a depth of 1cm
in a dipping motion.
• Then gently lift your fingers and move to the next area.

38. Deeply palpate all quadrants to delineate
abdominal organs and detect subtle masses
• Using the palmar surface of the fingers, compress to a
maximum depth (5 to 6 cm).
• Perform bimanual palpation if you encounter
resistance or assess deeper structures.
Palpate for masses
• Note their location, size, shape, consistency,
demarcation, pulsatility, tenderness, and mobility.
• Do not confuse a mass with a normally palpated
organ or structure.

39. Palpate the umbilicus and surrounding area for swellings, bulges, or masses
• Umbilicus and the surrounding area are free of swellings, bulges, or masses.

40. Palpate the aorta
• Use your thumb and first finger or two hands and palpate deeply in the epigastrium, slightly to
the left of the midline.
• Assess the pulsation of the abdominal aorta.

41. Palpate the liver
• Note consistency and tenderness.
• To palpate bimanually, stand at the client’s right side and place your left hand under the
client’s back at the level of the eleventh to twelfth ribs.
• Lay your right hand parallel to the right costal margin.
• Ask the client to inhale, then compress upward and inward with your fingers.

42. Palpate the kidneys
• To palpate the right kidney, support the right posterior flank with your left hand and place
your right hand in the RUQ just below the costal margin at the MCL.

43. Palpate the spleen
• Stand at the client’s right side, reach over the abdomen with your left arm, and place your
hand under the posterior lower ribs.
• Pull up gently. Place your right hand below the left costal margin with the fingers pointing
toward the client’s head.
• Ask the client to inhale and press inward and upward as you provide support with your other
hand.

44. Palpate the urinary bladder
• Palpate for a distended bladder when the client’s history or other findings warrant.
• Begin at the symphysis pubis and move upward and outward to estimate bladder borders.

45. Palpation Technique
• First explore superficial aspect each quadrant (start R lower , R upper, L upper, L lower)
• Deeper palpation
Liver
• Start R lower, moving up towards R ribs
• Move hands a few cm up with each palpation
• Push down(posterior) & then towards head
• As approach ribs, palpate while patient inspires deeply
• Diaphragm brings liver down towards hand
• Might feel liver edge in normal (usually not)
• Deeper Palpation

46. Spleen
• Palpate towards left upper quadrant from midline & below - can use L hand to “pull”
spleen towards you
Aorta (if RFs for aneurysm: Age > 60, smoking)
• Above umbillicus, left of midline
• Push down (deep) with palpating hand
Remainder of abdomen
• Uterus, bladder, other (rarely palpable)
• Evaluate painful areas last!

47. Palpating to Detect fluid Wave (ascites)
• Examiner’s right hand on patient’s right
• Push quickly & initiate a “wave” within ascites
• Receiving hand on Left identifies the wave
• A third hand dampens passage of wave through sub-cu fat
• Sensitivity: 62%
• Specificity: 90%

48. Palpation/Percussion of the Kidneys
• Kidneys are retroperitoneal structures, deep & protected by the ribs & rarely palpable
• If markedly enlarged, may appreciate in lateral aspects abdomen (rare)
• Assess for tenderness via posterior approach, tapping on back at Costo-Vertebral Angle –if
kidney infected (pyelonephritis), patient will have Tenderness (CVAT)
• Not done routinely – only in right clinical context
Exposed Deep Retroperitoneum

49. Put Findings Together & Paint The Best Picture
• Abdominal exam techniques compliment each other!
Ascites
• Observe distention, bulging flanks
• Palpation & no evidence of mass
• Palpation + fluid wave
Enlarged liver (Hepatomegaly)
• Percussion indicates extension of liver below diaphragm
• Palpation confirms location of lower edge (also detects contour, texture)

50. Summary of Skills
• Wash Hands
• Observe abdomen (shape, contours, scars, colour)
• Auscultate abdomen (bowel sounds, bruits)
• Percuss abdomen (general; then liver & spleen)
• Palpate 4 quadrants abdomen (superficial then deep)
• Assess for kidney area pain (CVAT)
• Wash Hands
Time Target: < 10 Minutes