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")
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:
signs of trauma
bulging flanks - best done from the foot of the bed
caput medusae - dilated blood vessels radiating from the
umbilicus (may be present in liver failure)
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
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 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
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.
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
rebound (release of pressure causes pain)
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
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.