Abdominal examination

The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.

The exam includes several parts:

• Setting and preparation
• Inspection (for example, "nondistended" or "ND")
• Auscultation (for example, "BS normoactive" or "BS+"
• Percussion
• Palpation (for example, "no hepatosplenomegaly" or "HSM", "soft", "nontender" or "NT")

Setting and preparation

Position - patient should be supine and the bed or examination table should be flat. The patient's hands should remain at his/her sides with his/her head resting on a pillow. If the neck is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend his/her knees so that the soles of their feet rest on the table will also relax the abdomen.

Lighting - adjusted so that it is ideal.

Draping - patient should be exposed from the pubic symphysis below to the costal margin above - in women to just below the breasts. Some surgeons would describe an abdominal examination being from nipples to knees.

Physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment. Separate systematic reviews by the Cochrane Collaboration and the Rational Clinical Examination refute this claim.

Inspection

The patient should be examined for: -

• masses
• scars, sinuses
• lesions
• signs of trauma
• bulging flanks - best done from the foot of the bed
• jaundice/scleral icterus
• abdominal distension
• caput medusae - dilated blood vessels radiating from the umbilicus (may be present in liver failure)
• cough impulse

Stigmata of liver disease

There are several stigmata of liver disease. Though not all of these are observed in the abdomen, they can indicate liver disease, and are sometimes grouped with local hepatic findings. These stigmata include:

• General: spider angiomata, temporal wasting, fetor hepaticus, asterixis (flapping tremor)
• Hands: clubbing, thenar wasting, Dupuytren's contracture, palmar erythema
• Estrogen related: spider nevi
  • Estrogen-related in males: testicular atrophy, gynecomastia
• Associated with portal hypertension: hematochezia (blood in stool), hematemesis - gastric bleed, esophageal varices, caput medusae (rare) - venous distension, ascites

Auscultation

Auscultation is sometimes done before percussion and palpation, unlike in other examinations. It may be performed first because vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus the bowel sounds. Additionally, it is the least likely to be painful/invasive; if the person has peritonitis and you check for rebound tenderness and then want to auscultate you may no longer have a cooperative patient.

Pre-warm the diaphragm of the stethoscope by rubbing it on the front of your shirt before beginning auscultation. One should auscultate in all four quadrants, but there is no true compartmentalization so sounds produced in one area can generally be heard throughout the abdomen. To conclude that bowel sounds are absent one has to listen for 5 minutes. Growling sounds may be heard with obstruction. Absence of sounds may be caused by peritonitis.

Another new technique to measure the borders of the liver is the "Kamil Ševela" technique, which I was taught in the hospital. You place the stethoscope on the xiphoid process for auscultation. You scratch from below the right nipple/breast and you hear clearly the liver borders. The first sound is when the liver appears, and when the sound disappears it is the end of the liver. The sounds are clearly audible, and it's a very useful tool to know the borders of the liver.^{[citation needed]}

Palpation

• All 9 areas - light then deep.
• In light palpation, note any palpable mass.
• In deep palpation, detail examination of the mass, found in light palpation, and Liver & Spleen
• Palpate the painful point at the end.

Assessing muscle tone- This is done by pressing a hand against the abdominal wall. There are 3 reactions that indicate pathology:

• guarding (muscles contract as pressure is applied)
• rigidity (rigid abdominal wall- indicates peritoneal inflammation)
• rebound (release of pressure causes pain)

• hernial orifices if positive cough impulses

Percussion

• it is common practice to start percussing in a quadrant where there is no pain/discomfort and to percuss the painful quadrant(s) last. making sure to percuss all the 9 areas.
• percuss the liver from the right iliac region to right hypochondrium
• percuss for the spleen from the right iliac region to the left hypochondrium and the left iliac to the left hypochondrium.

Examination of the spleen

• Castell's sign or alternatively Traube's space

Other

• Digital rectal exam - Abdominal examination is not complete without a digital rectal exam.
• Pelvic examination only if clinically indicated.

Special maneuvers

Suspected cholecystitis

• Murphy's sign

Suspected appendicitis or peritonitis

• Rebound tenderness - pain elicited by the release of palpation by the examiner
• Psoas sign - pain when tensing the psoas muscle
• Obturator sign - pain when tensing the obturator muscle
• Rovsing's sign - pain in the right iliac fossa on palpation of the left side of the abdomen
• Carnett's sign - pain when tensing the abdominal wall muscles
• Patafio's sign - pain when the patient is asked to cough whilst tensing the psoas muscle
• Cough test - pain when the patient is asked to cough

Suspected Pyelonephritis

• Murphy's punch sign

Hepatomegaly

• Liver scratch test

Examination for ascites

• bulging flanks
• fluid wave test
• shifting dullness

External links

• Abdominal exam - a practical guide to clinical medicine from the University of California, San Diego.
• Abdominal examination video
• Pediatric Abdominal examination video