History Vital Signs Abdominal Exam Breast Exam Pelvic Exam Rectal Exam Innoculations Treatment Resources

Abdominal Exam

 

The exam includes several parts:

Setting and preparation

Inspection (for example, "nondistended" or "ND")

Auscultation (for example, "BS normoactive" or "BS+"

Palpation (for example, "no hepatosplenomegaly" or "HSM", "soft", "nontender" or "NT")

Percussion

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.

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.

Ausculation

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 各vela" 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.

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)

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.

Digital rectal exam - Abdominal examination is not complete without a digital rectal exam.

Pelvic examination only if clinically indicated.

The doctor palpates Mrs. Wilson's abdomen.

Click to watch a demonstration.

    
       

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