EXAMINATION OF THE ABDOMEN

I. Preparation of the patient for abdominal examination

● Make sure the patient’s urinary bladder is not full
● Have the patient in supine position with the pillow under the head and the small
pillow under the knees with the arms on the sides, folded across the chest
● Expose the abdomen from the xiphoid process to the symphysis pubis
● If necessary, illuminate the abdomen using a single light source. Directed from
the feet to the head or from across the abdomen towards the examiner.
● Before palpation, ask the patient to point to any areas of pain and examine them
last.
● Examiner’s hands should be warm with short nails.
● Be gentle and approach patient slowly and avoid quick unexpected movements.
● If the patient is anxious, distract attention by talking to the patient

II. Inspection of the abdomen

● Describe the abdomen as to
○ symmetry
○ Skin
■ take note of the color
■ presence of lesions, scars
● describe as to location, size, shape and cause.
● Take note also of the shape, whether it is flat, globular,
scaphoid or protuberant.
● Note for the appearance of the umbilicus,
○ whether it is flat, inverted or everted.
○ Check for possible pulsation in the epigastric region. This may be seen
normally in thin individuals
● Observe for the following abnormal findings:
○ Bulging flanks and
○ Abnormal bulges
○ Dilated superficial blood vessels like capillaries and veins
○ Pulsations outside of the epigastric regions
○ Peristaltic waves and
○ Presence of mass
● Recording of result:
○ On inspection, the abdomen is symmetrical, the skin is brown, no lesions,
no scar. The shape is flat and the umbilicus is inverted. No bulging flanks
and no localized bulges. No dilated blood vessels, no abnormal
pulsations, no visible peristalsis and no mass

III. Auscultation of the abdomen

● To listen for and describe the bowel sounds, rest the diaphragm firmly on the
right lower quadrant and listen for gurgling or bubbling or popping sounds
 ● Describe the bowel sounds as to normal active.
○ If at rest, presence of 5-34 bowel sounds in one minute
○ If after meals, several bowel sounds every few seconds
○ Hyperactive- more frequent, almost continuous, louder, higher in pitch
compared to normal active.
○ Hypoactive- extremely weak or soft, barely audible and less than 5 bowel
sounds per minute
○ Absent- no bowel sound heard after 5 minutes of auscultation
○ Take note that it is possible to hear bowel sounds in all quadrants, but
easiest over the right lower quadrant
○ Recording of results: On auscultation, the bowel sounds are normal
active.

IV. Percussion of the abdomen

● To assess the distribution of air in the bowel, there are two basic sounds that can
be elicited-
○ Tympanitic or drum like sound produced by percussing air filled structures
○ Dull sounds that occur when a solid structure or fluid lies beneath the
region being examined
● Randomly percuss each of the four quadrants, normally the sound you will elicit
is tympanitic. This will not be equally tympanitic, since the underlying intestines
may be purely gas or liquid filled.
● Special note should be made if percussion produces pain, which may occur if
there is underlying infection as in peritonitis. This will certainly be supported by
other historical or examination findings.
● To measure the liver span,
○ start at the area of tympany from the below the level of the umbilicus
along the right midclavicular line.
○ Percuss upwards towards the liver.
○ Then mark the sight where the sound changes from tympany to dullness.
This is the lower border of the liver
○ Start at the area of resonance, just about the level of the 3rd or 4th
intercostal space right midclavicular line
○ Percuss downward
○ And mark the site where the sound changes from resonance to dullness
○ This is the upper border of the liver
○ The total span of a normal liver is quite variable depending on the size of
the patient between 6 and 12 cm.
○ At times, you may have a hard time picking out the different sounds as
the changes can be quite subtle particularly if there is a lot of
subcutaneous fat.
● To estimate the size of the spleen
○ Percuss along the left midaxillary line, starting from the area of resonance
on the 8th ICS down to the 11th ICS and listen for dullness.
 ○ The normal result should be: No dullness appreciated or splenic dullness
over one ICS from the 9th to the 11th ICS

V. Palpation of the abdomen

● Preparation of the patient before palpation to enhance complete muscle
relaxation.
● Keep palpating hand flat and parallel to the abdomen
● Ask the patient to breathe slowly in and out through the mouth
● In a very ticklish person,
○ palpate by placing the examiner’s hand over the patient’s hand.
○ As the ticklishness disappear, slip your hand underneath the patient’s
hand to palpate directly.
● There are two different types of palpation, the light and the deep palpation.
● There are two techniques in performing the deep palpation
○ First, is through the single handed technique
■ Using the palmar surface of the approximated fingers,
■ press the abdomen to a depth of about 4-5 cm
■ then glide the fingers back and forth.
■ Palpate each of the four quadrants of the abdomen
○ The double handed technique when deep palpation is difficult like in
obesity, increased muscle tone and when the target organ is deep
■ Place left hand on top of the right hand
■ The fingers of the left hand should press on the distal phalanges
of the right hand
■ The left hand reinforces the palpation by exerting pressure on the
right hand, while the right hand feels for organs, masses and other
abnormalities
■ Press the abdomen to a depth of about 4-5 cm then glide the
fingers back and forth
■ Palpate each of the four quadrants of the abdomen
● To palpate for the liver
○ Place the examiner’s left hand behind the patient, parallel to and
supporting the patient’s right 11th and 12th rib in adjacent soft tissues
below
○ Place the examiner’s right hand on the patient’s abdomen, parallel and
lateral to the rectus muscle with the fingertips well below the lower border
of the liver dullness
○ During expiration, rest the abdomen gently with the right hand, with the
left hand lifting the back
○ With the left hand lifting the back, glide the fingertips with the right hand
upward during the succeeding inspiration and feel for the liver edge as it
comes down and meets the fingertips.
○ The liver is normally not palpable, except in very thin individuals
 ○ If felt like in the pressure of the palpating hand slightly so the liver can slip
under the finger pads.
○ Normally, the liver edge is sharp, firm with smooth surface and non
tender.
● Hooking technique
○ This is helpful especially when the patient is obese.
○ Stand on the patient’s right side, facing his feet.
○ Place both hands side by side on the right abdomen below the border of
liver dullness.
○ Hook your fingers along the costal margin or below the level of liver
dullness and ask the patient to take a deep breath.
○ Repeat the maneuver several times and feel for the liver edge as it comes
down and meets the finger tips during inspiration.
○ The liver is not palpable, except in very thin individuals. Normally, it
should be firm, smooth even and non tender.
● To palpate for the spleen
○ Stand at the right side of the supine patient
○ Lay the palm of the right hand on the abdominal wall in the left upper
quadrant
○ and place the tips of the approximated fingers just inferior to the rib
margin, along the left anterior axillary line
○ Place the palm of the left hand on the left mid axillary region of the thorax
○ With the fingers ​grading​ posteriorly, support the thoracic wall at the 11th
and 12th ribs
○ Ask the patient to inspire deeply and slowly through the mouth
○ During inspiration, bring the two hands closer together by lifting the
posterior wall with the left hand by firmly pushing the approximated
fingers of the right hand inward and upward behind the costal margin
○ Alternatively, in obese or big patients do the procedure with the patient
lying partially on his right side with legs somewhat flexed at hips and
knees
● Middleton technique
○ Stand at the patient’s left side and facing his feet
○ Ask the patient to place his left fist behind his left thoard at the level of the
11th and 12th ribs
○ Curl both your hands over the left costal margin so your fingertips are
pointing upward behind the ribs
○ Feel for the splenic edge as the patient inspire deeply
● Palpating the left kidney using the capture technique
○ Stand on the left side of the patient
○ Place the palm of the right hand behind the patient just below and parallel
to the 12th rib with fingertips reaching the costovertebral angle then lift
anteriorly
 ○ Place the left hand gently on the left upper quadrant, lateral and parallel
to the rectus muscle.
○ Ask the patient to inspire deeply.
○ At the peak of inspiration, try to capture the kidney between your two
hands by pressing the left hand firmly and deeply into the left upper
quadrant just below the costal margin
○ Ask the patient to breath our and pause
○ Slowly release the pressure of the left hand, feeling for the kidney to slide
back into its expiratory position
○ Normally, the left kidney is not palpable
● Palpation of the right kidney using the capture technique
○ Stand at the right side of the supine patient
○ Place the left hand just below and parallel to the 12th rib with fingertips
reaching the costovertebral angle then lift anteriorly
○ Place the right hand at the patient’s right upper quadrant lateral and
parallel to the rectus muscle
○ Ask the patient to take a deep breath
○ At the peak of inspiration, try to capture the kidney between your two
hands by pressing the right hand firmly and deeply into the right upper
quadrant just below the costal margin.
○ Ask the patient to breath our and pause
○ Slowly release the pressure of the right hand, feeling for the kidney to
slide back into its expiratory position
○ The right kidney is usually not palpable
○ When palpable it should remain smooth, rounded and non tender.