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Abdominal examination

Last updated: December 2, 2019

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A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultation, percussion, and palpation. The examination begins with the patient in supine position, with the abdomen completely exposed. The skin and contour of the abdomen are inspected, followed by auscultation, percussion, and palpation of all quadrants. Depending on the findings or patient complaints, a variety of examination techniques and special maneuvers can provide additional diagnostic information.

Positioning

  • Instruct the patient to lie down and expose the patient's abdomen.
  • If your hands are cold, warn the patient prior to palpating the abdomen.

Inspection of the abdomen

  • Note any scars, striae, vascular changes (e.g., caput medusae), or protrusions
  • Note the general contour of the abdomen

Auscultation of the abdomen

Auscultation of the abdomen should be performed prior to percussion and palpation, as physical manipulation of the abdomen may induce a change in bowel sounds.

  • Purpose: to assess bowel sounds
  • Auscultate over all four quadrants.
  • Listen for bruits.
  • Normal findings: : gurgling bowel sounds every 5–10 sec

Percussion of the abdomen

  • Purpose: to determine the size and location of intra-abdominal organs
  • Percuss over all four quadrants.
  • Normal findings: tympanic sound over air-filled stomach/intestinal sections; muffled sounds over fluid-filled or solid organs (liver, spleen)

Palpation of the abdomen

  • Purpose: to evaluate internal organs and identify any sources of pain (if present)
  • Prior to palpation, ask the patient whether they have abdominal pain or tenderness. If so, begin palpation in the non-painful area.
  • Observe the patient's face during abdominal palpation, as it is the main indicator of the intensity and location of pain.
  • Procedure:
    1. Superficial palpation: to assess for superficial or abdominal wall processes
    2. Deep palpation in all four quadrants: to assess intraabdominal organs (potential signs of peritonitis)
      • Rebound tenderness: abrupt increase in pain when an examiner suddenly releases compression of the abdominal wall. Caused by irritation of the receptors in parietal peritoneum
      • Abdominal guarding: patient contraction of the abdominal wall muscles during palpation
        • Involuntary guarding (also referred to as "rigidity"): involuntary tightening of the muscles due to peritoneal inflammation and is often localized to a specific abdominal quadrant.
        • Voluntary guarding: voluntary contraction in order to avoid pain during the examination and is often generalized over the entire abdomen.
    3. Palpation of the liver
    4. Palpation of the spleen
    5. Palpation of the inguinal lymph nodes: (see examination of the lymph nodes)

Abdominal tenderness may be a sign of numerous conditions (see differential diagnosis of acute abdomen and differential diagnoses of abdominal pain).

Liver size

  • Percussion
    • Place the middle finger of your non-dominant hand against the abdominal wall. With the tip of the middle finger of your dominant hand, strike the distal interphalangeal joint 2–3 times.
    • Start below the breast at the midclavicular line. Percuss as you move your hand downward and note the sound change as you transition from lung (resonant) to liver (dull). Continue until the sound changes again after the inferior margin of the liver.
  • Liver scratch test
  • Normal findings: : The normal craniocaudal liver size is 7–11.5 cm in women and 8–12.5 cm in men. In most patients, the liver is fully covered by the ribs.
  • Hepatomegaly

Special tests

Common causes of abdominal pain (based on location)

Causes of diffuse or generalized abdominal pain

Causes of acute abdomen

  1. Bickley L. Bates' Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins ; 2012
  2. A Practical Guide to Clinical Medicine. https://meded.ucsd.edu/clinicalmed/. Updated: September 1, 2004. Accessed: January 10, 2018.
  3. Penner RM, Fishman MB. Causes of abdominal pain in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/causes-of-abdominal-pain-in-adults.Last updated: November 2, 2017. Accessed: January 18, 2018.
  4. Sokol HN. Preventive care in adults: Recommendations. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/preventive-care-in-adults-recommendations.Last updated: November 26, 2017. Accessed: January 18, 2018.