Abdomen:

Switches to Inspection, Auscultation, Percussion, and Palpation

 Have patient lay supine

 Ask patient about their last about bowel movement and if they have any problems with
urination. If a female patient, ask when their last menstrual period was.
 If an ostomy is present note the type of ostomy, stoma color (should be pink and shiny),
consistency and color of stool?

Inspect:

 Stomach contour scaphoid, flat, rounded, protuberant?

 Noted pulsations at the aorta (noted in thin patients): The aortic pulsation can be
noted above the umbilicus.
 Characteristics of the navel (invert or everted)
 Masses (check for hernia after auscultation), PEG tube?
Auscultate with the diaphragm for bowel sounds:

 start in the RIGHT LOWER QUADRANT and go clockwise in all the 4 quadrants

o should hear 5 to 30 sounds per minute…if no, bowel sounds are

noted listen for 5 full minutes
o Documents as: normal, hyperactive, or hypoactive
Auscultate for bruits (vascular sounds) at the following locations using the BELL of the
stethoscope:

 Aorta: slightly below the xiphoid process midline with the umbilicus
 Renal Arteries: go slightly down to the right and left at the aortic site
 Iliac arteries: go few a inches down from the belly button at the right and left sides to
listen
 Femoral arteries: found in the right and left groin.
Check for hernia: have patient raise up a bit and look for hernia (at stomach area or navel area)

Palpation of the abdomen:

 Light palpation (2 cm): should feel soft with no pain or rigidity

 Deep palpation (4-5 cm): feel for any masses, lumps, tenderness
Abdominal inspection

Position the patient lying flat on the bed, Stomas

with their arms by their sides and legs
uncrossed for abdominal inspection and If a stoma is present, assess the following
subsequent palpation. characteristics:

Inspect the patient’s abdomen for signs  Location: this can provide clues as to
suggestive of gastrointestinal pathology: the type of stoma (e.g. colostomies
are typically located in the left iliac
 Scars: there are many different fossa, ileostomies and urostomies
types of abdominal scars that can are typically located in the right iliac
provide clues as to the patient’s past fossa).
surgical history (see image below for  Contents: can be stool (e.g.
examples). colostomy or ileostomy) or urine
 Abdominal distension: can be (e.g. urostomy).
caused by a wide range of pathology  Consistency of stool: note if it is
including the six f’s (fat, fluid, flatus, liquid (ileostomy) or solid
faeces, fetus or fulminant mass). (colostomy).
 Caput medusae: engorged  Spout: colostomies are flush to the
paraumbilical veins associated with skin with no spout whereas
portal hypertension (e.g. liver ileostomies and urostomies have a
cirrhosis). spout.
 Striae (stretch marks): caused by
tearing during the rapid growth or Abdominal palpation
overstretching of skin (e.g. ascites,
intrabdominal malignancy, Cushing’s Preparation
syndrome, obesity, pregnancy).
 Hernias: ask the patient to cough Before beginning abdominal palpation:
and observe for any protrusions
through the abdominal wall (e.g.  The patient should already be
umbilical hernia, incisional hernia). positioned lying flat on the bed.
 Cullen’s sign: bruising of the tissue  Ask the patient if they are aware of
surrounding the umbilicus any areas of abdominal pain (if
associated with haemorrhagic present, examine these areas last).
pancreatitis (a late sign).  Kneel beside the patient to carry out
 Grey-Turner’s sign: bruising in the palpation and observe their face
flanks associated with haemorrhagic throughout the examination for
pancreatitis (a late sign). signs of discomfort.

Light palpation of the abdomen

Lightly palpate each of the nine abdominal If any masses are identified during deep
regions, assessing for clinical signs palpation, assess the following
suggestive of gastrointestinal pathology: characteristics:

 Tenderness: note the abdominal  Location: note which of the nine

region(s) involved and the severity abdominal regions the mass located
of the pain. within.
 Rebound tenderness: said to be  Size and shape: assess the
present when the abdominal wall, approximate size and shape of the
having been compressed slowly, is mass.
released rapidly and results in  Consistency: assess the consistency
sudden sharp abdominal pain. This is of the mass (e.g. smooth, soft, hard,
a non-specific, unreliable clinical sign irregular).
that can, in some cases, be  Mobility: assess if the mass appears
associated with peritonitis (e.g. to be attached to superficial or
appendicitis). underlying structures.
 Guarding: involuntary tension in the  Pulsatility: note if the mass feels
abdominal muscles that occurs on pulsatile, suggestive of vascular
palpation associated with peritonitis aetiology (e.g. abdominal aortic
(e.g. appendicitis, diverticulitis). aneurysm).
 Rovsing’s sign: palpation of the left
Palpate the liver
iliac fossa causes pain to be
1. Begin palpation in the right iliac fossa,
experienced in the right iliac fossa.
starting at the edge of the superior iliac
This sign was historically said to be
spine, using the flat edge of your hand (the
indicative of appendicitis, but it is
radial side of your right index finger).
not reliable and at best indicates
peritoneal inflammation of any
2. Ask the patient to take a deep breath and
cause affecting the left and/or right
as they begin to do this palpate the
iliac fossa.
abdomen. Feel for a step as the liver edge
 Masses: large or superficial masses
passes below your hand during inspiration
(e.g. hernias) may be noted on light
(a palpable liver edge this low in the
palpation.
abdomen suggests gross hepatomegaly).
Deep palpation of the abdomen
3. Repeat this process of palpation moving
Palpate each of the nine abdominal regions 1-2 cm superiorly from the right iliac fossa
again, this time applying greater pressure to each time towards the right costal margin.
identify any deeper masses. Warn the
patient this may feel uncomfortable and ask 4. As you get close to the costal margin
them to let you know if they want you to (typically 1-2 cm below it) the liver edge
stop. You should also carefully monitor the may become palpable in healthy individuals.
patient’s face for evidence of discomfort (as
they may not vocalise this). If you are able to identify the liver edge,
assess the following characteristics:
 the gallbladder is enlarged, a well-defined
 Degree of extension below the round mass that moves with respiration
costal margin: if greater than 2 cm may be noted. Tenderness suggests a
this suggests hepatomegaly. diagnosis of cholecystitis whereas a
 Consistency of the liver edge: a distended painless gallbladder may indicate
nodular consistency is suggestive of underlying pancreatic cancer (particularly if
cirrhosis. also associated with jaundice).
 Tenderness: hepatic tenderness may
suggest hepatitis or cholecystitis (as Murphy’s sign
you may be palpating the 1. Position your fingers at the right costal
gallbladder) margin in the mid-clavicular line at the
 Pulsatility: pulsatile hepatomegaly is liver’s edge.
associated with tricuspid
regurgitation. 2. Ask the patient to take a deep breath.

Causes of hepatomegaly If the patient suddenly stops mid-breath

There is a wide range of possible causes of due to pain, this suggests the presence of
hepatomegaly including but not limited to: cholecystitis (known as “Murphy’s sign
positive”).
 Hepatitis (infective and non-
infective) Palpate the spleen
 Hepatocellular carcinoma 1. Begin palpation in the right iliac fossa,
 Hepatic metastases starting at the edge of the superior iliac
 Wilson’s disease spine, using the flat edge of your hand (the
 Haemochromatosis radial side of your right index finger).
 Leukaemia
 Myeloma 2. Ask the patient to take a deep breath and
 Glandular fever as they begin to do this palpate the
 Primary biliary cirrhosis abdomen with your fingers aligned with the
 Tricuspid regurgitation left costal margin. Feel for a step as the
splenic edge passes below your hand during
 Haemolytic anaemia
inspiration (the splenic notch may be
noted).
Palpate the gallbladder
In healthy individuals, the gallbladder is not
3. Repeat this process of palpation moving
usually palpable. If the gallbladder is
1-2 cm superiorly from the right iliac fossa
palpable it suggests enlargement secondary
each time towards the left costal margin.
to biliary flow obstruction (e.g. pancreatic
malignancy, gallstones) and/or infection
In healthy individuals, you should not be
(e.g. cholecystitis).
able to palpate the spleen. A palpable
spleen at the edge of the left costal margin
Palpation of the gallbladder can be
would suggest splenomegaly (for the spleen
attempted at the right costal margin, in the
to be palpable at this location it would need
mid-clavicular line (the tip of the 9th rib). If
to be approximately three times its normal
size). In healthy individuals, the kidneys are not
usually ballotable, however, in patients with
a low body mass index, the inferior pole can
sometimes be palpated during inspiration.
Causes of splenomegaly
There is a wide range of possible causes of Causes of enlarged kidneys
splenomegaly including but not limited to:  Bilaterally enlarged, ballotable
 Portal hypertension secondary to kidneys can occur in polycystic
liver cirrhosis kidney disease or amyloidosis.
 Haemolytic anaemia  A unilaterally enlarged, ballotable
 Congestive heart failure kidney can be caused by a renal
 Splenic metastases tumour.
 Glandular fever
 Spleen palpation (splenomegaly) Palpate the aorta
 Palpate the spleen 1. Using both hands perform deep palpation
 Splenomegaly just superior to the umbilicus in the midline.
 Splenomegaly 27
2. Note the movement of your fingers:
Ballot the kidneys
1. Place your left hand behind the patient’s  In healthy individuals, your hands
back, below the ribs and underneath the should begin to move superiorly
right flank. with each pulsation of the aorta.
 If your hands move outwards, it
2. Then place your right hand on the suggests the presence of an
anterior abdominal wall just below the right expansile mass (e.g. abdominal
costal margin in the right flank. aortic aneurysm).

3. Push your fingers together, pressing This is a crude clinical test and further
upwards with your left hand and investigations would be required before a
downwards with your right hand. diagnosis of an abdominal aortic aneurysm
was made.
4. Ask the patient to take a deep breath and
as they do this feel for the lower pole of the Palpate the bladder
kidney moving down between your fingers. Before performing bladder palpation, allow
This bimanual method of kidney palpation is the patient the opportunity to go to the
known as balloting. toilet. Warn the patient that palpation may
be uncomfortable and bring about the
5. If a kidney is ballotable, describe its size sudden urge to pass urine.
and consistency.
A distended bladder can be palpated in the
6. Repeat this process on the opposite side suprapubic area arising from behind the
to ballot the left kidney. pubic symphysis (e.g. urinary
obstruction/retention). In most healthy
patients who are passing urine regularly, Percussion can also be used to assess for
the bladder will not be palpable. the presence of ascites by identifying
shifting dullness:

1. Percuss from the umbilical region to the

patient’s left flank. If dullness is noted, this
Abdominal percussion may suggest the presence of ascitic fluid in
Percuss the liver the flank.
1. Percuss upwards 1-2 cm at a time from
the right iliac fossa (the same position used 2. Whilst keeping your fingers over the area
to begin palpation) towards the right costal at which the percussion note became dull,
margin until the percussion note changes ask the patient to roll onto their right side
from resonant to dull indicating the location (towards you for stability).
of the lower liver border.
3. Keep the patient on their right side for 30
2. Continue to percuss upwards 1-2 cm at a seconds and then repeat percussion over
time until the percussion note changes from the same area.
dull to resonant indicating the location of
the upper liver border. 4. If ascites is present, the area that was
previously dull should now be resonant (i.e.
3. Use the knowledge of the upper and the dullness has shifted).
lower border of the liver to determine its
approximate size. Abdominal auscultation
Assess bowel sounds
Percuss the spleen Auscultate over at least two positions on
Percuss upwards 1-2 cm at a time from the the abdomen to assess bowel sounds:
right iliac fossa (the same position used to  Normal bowel sounds: typically
begin palpation) towards the left costal described as gurgling (listen to an
margin until the percussion note changes example in our video
from resonant to dull indicating the location demonstration)
of the spleen (in the absence of  Tinkling bowel sounds: typically
splenomegaly the spleen should not be associated with bowel obstruction.
identifiable using percussion).  Absent bowel sounds: suggests ileus
which is a disruption of the normal
Percuss the bladder propulsive ability of the intestine
Percuss downwards in the midline from the due to a malfunction of peristalsis.
umbilical region towards the pubic Causes of ileus include electrolyte
symphysis. A distended bladder will be dull abnormalities and recent abdominal
to percussion allowing you to approximate surgery. To be able to confidently
the bladder’s upper border. state that a patient has ‘absent
bowel sounds’ you need to
Assess shifting dullness auscultate for at least 3 minutes
(this is unlikely to be the case in an
OSCE given the time restraints).
Listen for bruits
Auscultate over the aorta and renal arteries
to identify vascular bruits suggestive of
turbulent blood flow:
 Aortic bruits: auscultate 1-2 cm
superior to the umbilicus, a bruit
here may be associated with an
abdominal aortic aneurysm.
 Renal bruits: auscultate 1-2 cm
superior to the umbilicus and slightly
lateral to the midline on each side. A
bruit in this location may be
associated with renal artery
stenosis.

REFERENCE:
https://geekymedics.com/abdominal-
examination/