Examination of Abdomen

Before starting:

 Position:
o Supine, hands by the side, legs extended for inspection, flexed for palpation
 Exposure:
o Nipples to mid-thigh. Ask for a screen before starting or cover the genitalia with a sheet
 Introduction and consent

Relevant GPE:

 Pulse rate and volume

 Pallor, jaundice and hydration

Inspection:

 Do it from foot end as well as side (sit down at the level of the patient, when on side)
 Shape:
o Scaphoid
o Flat or protuberant
o Flanks full or not
 Is it moving normally with respiration
 Umbilicus:
o Normal
o Everted
o Transervese/vertical slitting
 Any visible swelling
 Misc. Things:
o Scars
o Sinuses
o Visible pulsations
o Hair distribution
o Visible veins

Palpation:

 Ask for any painful area before starting, always start from non-tender area
 Use appropriate technique: Don’t poke the fingers
 Move in S-shaped manner and place the hand once in each quadrant of abdomen
 Hand and forearm should be at same level i.e at the level of abdomen
Superficial palpation:

 Just move the hand superficially across the patient’s abdomen to gain patient’s confidence and
tenderness

Deep palpations:

 Note any tenderness, guarding or rigidity

 If palpable mass; note:
o Movement with respiration (Retro-peritoneal swellings don’t move with respiration
while the intraperitoneal swelling do)
o Carnet’s sign:
 Ask the patient to lift the head slightly. The abdominal muscles get taut and
swelling if intraperitoneal i.e. deep to muscles, will decrease in size. In case of
paraumbilical or epigastric hernias, you can feel the defect in linea alba during
this maneuver.
o Rest of the examination is same as given for swelling
 Special signs:
o Appendicitis:
 Pointing:
 Patient points at McBurney’s when asked to paint at site of maximum
pain
 Rovsing’s sign:
 Deep palpation in left iliac fossa causes pain in right iliac fossa.
 Psoas:
 Place patient in left lateral position and hyperextend the leg at hip joint.
Pain with this maneuver signifies retrocecal appendix
 Obturator:
 Flex the leg at knee and internally rotate at hip. Pain with this maneuver
signifies pelvic appendix
 Rebound tenderness:
 Deelply palpate in right iliac fossa, then withdraw the hand suddenly
and completely, patient will wince with pain.
o Cholecystitis:
 Murphy’s signs:
 Palpate at the level of 9th costal margin and with inspiration press the
hand upwards and deep. Patient will wince with pain as the inflamed
gall bladder touches the hand
o Perforated peptic ulcer:
 Normal liver dullness will be obliterated
 Palpation for viscera:
 o Liver, start from right iliac fossa, going towards the right hypochondrium, if palpable
note:
 Edge, tenderness, consistency, regularity
 Total span by percussion from above and below (normal up to 12 cm)
o Kidneys:
 Palpate bimanually, one hand behind lumbar region reaching upto erector
spinae border, other hand anteriorly
 If palpable elicit ballotment; The hand behind pushes the kidney anteriorly
which is felt by the hand on anterior side.
o Bladder:
 Palpate from epigastrium downwards. Use left hand for palpation. If palpable,
confirm by percussion
o Spleen:
 Palpate from right iliac fossa going towards left hypochodrium. If palpable note:
 Consistency
 Notch in the anterior border
 Movement with respiration
 Confirm by percussion
 Measure how many cm below the costal margin
 If not palpable, try to palpate by:
 Placing left hand behind to palpate bimanually
 In right lateral position
o Aortic and paraaotic lymph nodes in the midline between xiphoid and umbilicus, Use
the tips of fingers of both hands

Percussion:

 Fluid thrill:
o Tap with one finger at flank and place hand at other flank to feel the thrill
 Shifting dullness:
o Start in the centre and move towards flanks. If note gets dull, turn the patient so that
side with dull note is up. Wait for 40-60 seconds and then percuss at the dull spot in the
same turned position. If now the dullness disappears, the test is positive

Ausculatation:

 Listen for Bowel sounds in right iliac fossa. Normally one in every 15 sec. Listen for at least 1 min
before declaring then absent.
 Succusion splash: Auscultate in left hypochondrium while shaking patient from side to side
 Listen for bruits: liver, Renal and aorta

In the end Don’t forget to examine:

  Hernial Orifices:
o Look at inguinal region and ask the patient to cough. Note for any visible swelling
 External genitalia:
o Any swelling, ulcer etc
 Digital Rectal examination:
o In left lateral position
o Knee elbow position
 Make the patient sit, inspect back and feel supraclavicular lymph nodes

Thank the patient and help him to redress

Relevant questions:

 According to findings encountered.

How to describe:

 My patient is a --- aged man with --- built --- (jaundice or pale), --- (well hydrated) and has a ---
(shape) abdomen which is moving --- (normally) with respiration with --- (inverted) umbilicus
and --- scar marks, visible veins etc.
 There is --- no visceromegaly, fluid thrill and shifting dullness test is --- for ascites and bowel
sounds are --- (audible)
 If visceromegaly, describe As --- e.g Liver is enlarged and palpable 4 cm below right costal
margin with at total span of 16 cm. It has a regular, non-tender edge with firm consistency
 Hernial orifices are intact, genitalia are --- , the back is --- and there is --- supraclavicular or
inguinal lymphadenopathy. Digital rectal examination is ----