Specific Examination: Abdomen & Acute Abdomen: Differential Diagnosis

Techniques Findings
Inspection: General appearance of patient:
 Lying quietly
 Writhing with discomfort
 Gripping one side
 Cachexia
 Pallor
 Jaundice
Contour of abdomen:
 Symmetry/Asymmetry
 Distension
 Bulge (Position, shape, size, shape, moves with respiration/ increases with
coughing)
 Peristalsis
Skin of abdomen:
 Scars, sinuses or fistulae
 Temperature (Warm/ cool/ clammy)
 Color (Bruises, erythema, jaundice)
 Striae (Old silver/ stretch marks are normal/ pink-purple are hallmark of
Cushing syndrome)
 Dilated veins
 Rashes/ecchymoses
Light Palpation:  Tenderness
-Perform while sitting down  Guarding
-Keeping your hand and forearm on a horizontal plane with  Rebound tenderness
fingers together flat on abdominal wall
-Palpate with gentle dipping motion
-Palpate in ‘S’ motion starting from right iliac fossa
*Avoid rapid, jerky or circular movements

Deep Palpation:  Mass (position, shape, size, surface, edge, pulsatility)

-Same as light palpation but need to press your hand during
palpation
Liver Palpation:  If liver is grossly enlarged:
-Place your right hand transversely and flat on the right side of -Lower edge will move downwards and bump against the radial side of your
the abdomen at the level of umbilicus, parallel with the right index finger
costal margin -Liver edge may be straight or irregular, thin and sharp or thick and rounded
-Ask patient to take a deep breath (moving upward when patient
exhale)
Spleen Palpation:  Normal spleen is not palpable
-With your left hand reach over and around the patient to  If really enlarged may be palpable at the right iliac fossa
support and press forward the lower left rib cage and adjacent
soft tissue
-With your right hand below the left costal margin, press in
towards the spleen
-Ask patient to take a deep breath
Kidney Ballottement:  Normal left kidney is rarely palpable
Left kidney:-  Right kidney may be slightly tender
-Move to patient’s left side
-Place your right hand behind the patient, just below and parallel
to the 12th rib with your fingertips just reaching the
costovertebral angle
-Lift the kidney to try to displace it anteriorly
-Place your hand gently in the LUQ, lateral and parallel to the
rectus muscle
-Ask patient to take a deep breath. At peak of inspiration, press
your hand firmly and deeply into LUQ just below the costal
margin
-Try to capture the kidney between your two hands
-Slowly release the pressure of your left hand when patient
breathe out

Right kidney:-
-Move to patient’s right side
-Use your left hand to lift up from the back and your right hand to
feel deep in the RUQ
-Proceed as before
Percussion:  Note any dullness or tympany

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-Percuss the abdomen lightly in all 9 regions  Dullness: Underlying mass or enlarges organ, fluid
-Percuss onto your left middle finger  Tympany: Gas in GI tract
-Percuss using your wrist and not your whole arm
Liver Percussion:  Normal liver span: 6-12 cm in right midclavicular line
-Identify midclavicular line
-Starting at a level well below the umbilicus in the right iliac fossa,
percuss upward toward the liver
-Identify the lower border of dullness in the midclavicular line
-Next, identify upper border of liver dullness.
-Starting at the nipple line, percuss downward in the
midclavicular line until lung resonance shifts to liver dullness
-Measures in cm the distance between your two points
Spleen Percussion:  If tympany is prominent especially laterally, splenomegaly is unlikely
-Percuss the left lower anterior chest wall roughly from the
border of cardiac dullness at the 6th rib to the anterior axillary line
and down to the costal margin (Traube space)
Kidney Percussion (Renal punch):  Normal kidneys: No pain
-Place the ball of one hand in CVA and strike it with the ulnar
surface of your fist.
-Use enough force to cause a perceptible but painless jar or thud
Auscultation:  Normal sounds: Gurgling
-Place the diaphragm of your stethoscope gently on abdomen  High pitched tinkling sound: Bowel obstruction
starting from the right lower quadrant for 5-10 seconds (assess all  Absent sound: Paralytic Ileus
4 quadrants)  Aortic bruit: Aortic aneurysm
- Aortic bruit:  Renal bruit: Renal artery stenosis
Auscultate 2 cm above umbilicus
-Renal bruit:
Auscultate 2cm above umbilical and 2 cm to the left and right
Special Techniques:
-Ascites
-Appendicitis
-Acute cholecystitis
Shifting Dullness:  In a person without ascites: The border between tympany and dullness
-Percuss the border of tympany and dullness with the patient usually stays relatively constant
lying supine

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-Then ask patient to roll onto one side  In ascites: Dullness shift to the more dependent side whereas tympany shifts
-Percuss and mark the borders again to the top

Fluid Thrill:  Often negative until ascites is obvious

-Ask the patient or assistant to place the edge of their hand on  Ripple felt against left hand after flicking
the midline of the abdomen (Preventing transmission of the
impulse via the skin rather than through the ascites)
-Place the palm of your left hand flat against the left side of the
abdomen and flick a finger of your right hand against the right
side of the abdomen
-If there you feel a ripple against your left hand a fluid thrill is
present
Assessing Possible Appendicitis:  Positive McBurney point tenderness: 3x more likely to have acute
-Ask the patient to point where the pain began and where it is appendicitis
nos. Ask patient to cough to see where the pain occurs  Tenderness in RLQ, Rovsing sign and Psoas sign: 2x more likely
-Palpate carefully the area of local tenderness  Irritation of psoas muscle is d/t inflamed appendix
-McBurney point: Lies 2 inches from the anterior superior spinous  Right hypogastric pain is a positive obturator sign from irritation of the
process of ilium on a line drawn from that process to the obturator muscle by an inflamed appendix
umbilicus
-Palpate the tender area for guarding, rigidity and rebound
tenderness
-Palpate for Rovsing sign and referred rebound tenderness. Press
deeply and evenly in the LLQ. Then quickly withdraw your fingers.
(Pain in RLQ during left sided pressure is a positive Rovsing sign)
-Assess the psoas sign: Place your hand just above the patient’s
right knee and ask patient to raise the thigh against your hand.
Alt, ask the patient to turn onto the left side. Extend the patient’s
right leg at the hip. Felxion of the leg at the hip makes the psoas
muscle contract; extension stretches it
-Assess obturator sign: Flex the patient’s right thigh at the hip,
with knee bent and rotate the leg internally at the hip. This
maneuver stretches the internal obturator muscle
Murphy Sign Assessment:  Positive Murphy sign when patient catch another breath d/t pain
- Place your right hand transversely and flat on the right side of
the abdomen below right costal margin
-Ask patient to take a deep breath

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 Differential Diagnosis Positive Findings During Physical Examination
Upper Abdominal Pain
Oesophagitis On examination rarely reveals diagnostic signs. The diagnosis relies on endoscopy, X-ray, FBC
Boerhaave’s Syndrome + Tender
+ Guarding Upper Abdomen
+ Rigid
+ Supraclavicular subcutaneous emphysema (Feel like little plastic air pockets in ‘bubble wrap’ which
compress, crackle and pop beneath the fingers during gentle palpation)
Acute gastritis/duodenitis/peptic + Epigastric tenderness
ulceration + Guarding
+ Anaemic (if there has been chronic silent bleeding before the acute episode)
Chronic peptic ulceration, gastritis + Inspection:
and duodenitis -Epigastric distension
-Visible peristalsis
+ Palpation:
-Mild tenderness in epigastric region
-Presence of succussion splash
+ Percussion and auscultation:
-Normal
Perforated peptic ulcer + General appearance:
-Lying completely still
-Tachycardia
-Shallow respiration
-Normal temperature
+ Inspection:
-Flat and does not rise and fall with respiration
-Abdominal muscles is tightly contracted
+ Palpation
-In early stage tenderness and guarding of the abdomen may be confined to the epigastrium and right
side

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 -When whole peritoneal cavity is contaminated, the whole abdomen becomes very tender with intense
guarding (Board-like rigidity)
-No intra-abdominal viscus or masses can be felt because the abdominal musculature is permanently
contracted
+ Percussion
-Painful
-Liver dullness may be diminished or completely absent (Large quantity of air has escaped into peritoneal
cavity)
+ Auscultation
-Bowel sound disappear

Carcinoma of the stomach + General appearance

-Cachexia
-Pallor
+ The neck
-Palpable supraclavicular gland (Virchow’s gland  Troisier’s sign)
+The lungs
-Presence of pleural effusion
+Abdomen
-Inspection:
--Scaphoid d/t weight loss
--Generalized abdominal distension if ascites present
--Epigastric distension
--Visible peristalsis
+Palpation
--May reveal epigastric mass (hard, irregular, dull, moves with respiration in advanced disease)
--Liver may be palpable and its edge and surface knobbly and irregular
+Percussion
--Shifting dullness
+Auscultation
--Normal bowel sound
Acute cholecystitis +Inspection

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Gallstone colic/Biliary colic
Acute pancreatitis
Acute Meckel’s Diverticulitis
Inflammatory bowel disease
Acute appendicitis
-Fullness in the right hypochondrium
+Palpation
--Tenderness and guarding in right hypochondrium
--Positive Murphy’s sign
+General appearance
-Mild tachycardia
-Jaundice
+Abdomen
-Tender
-Intense guarding in the upper abdomen
+General appearance
-Lie still
-Hypovolaemic (pale and sweating)
+ Abdomen
-Inspection
-- Tenderness and guarding in the upper abdomen
--Bruising and discoloration in the left flank and around the umbilicus
-Percussion
--Cause pain if there is peritonitis
--Dull over any pseudocysts
-Auscultation
--Bowel sound fade away is paralytic ileus develops
Central Abdominal Pain
+ Indistinguishable from acute appendicitis although the pain and tenderness are genrally felt more
towards the centre of the abdomen than in right iliac fossa
Acute Crohn’s Disease:
+Thick and tender terminal ileum may be palpable in right iliac fossa
+Thickened ileum and jejunum palpable in the umbilical region
Lower Abdominal Pain
+General appearance
-Flushed cheeks
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PID/ Acute salpingitis
Acute diverticulitis of the colon
-Low grade pyrexia
+Head and neck
-Furred tongue and foetor oris
+Abdomen
-Inspection
--Slightly distended
-Palpation
--Tender right iliac fossa and guarding
--Release or rebound tenderness in right iliac fossa
--Positive Rovsing’s sign
+Hip movement
-Extension of the right hip joint will exacerbate the pain if the appendix is in retrocaecal position lying
against the psoas muscle
-Pain on external and internal rotation of the hip indicates the appendix is lying against the obturator
internis muscle
+Palpation
-Tenderness and some guarding are present across the lower abdomen
-The tenderness often bilateral (Both fallopian tube may be affected)
-Lower and near mid-line
+General appearance
-Pyrexia
-Tachycardia
+Abdomen
-Inspection
--Moves with respiration
--Distended (If generalized peritonitis or intestinal obstruction occur)
-Palpation
--Tenderness and guarding in the left iliac fossa
--Palpable sausage-shaped mass in left iliac fossa
--Reversed Rovsing’s sign
--Rebound tenderness (If generalized peritonitis has developed)
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