COMPLETE PHYSICAL EXAMINATION OF THE ABDOMEN Mnemonics: PUSH V LAPS

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There are several points to remember prior to beginning the abdominal examination. These include: Auscultation provides important information about the bowel motility
1. Have patient empty bladder prior to examination Steps:
2. Use proper lighting and warm hands to examine abdomen 1. place the diaphragm of your steth gently on the abdomen
- You can rub your palm together or place them under warm water 2. listen for the sounds and note their frequency
3. Undrape abdomen from above xiphoid process to symphysis pubis. Groin area should be visible with genitalia 3. normal sounds consist of gurgles and clicks occurring at 5- 34
AUSCULTATION
draped. per min
4. Visualize each organ in the region under examination 4. since the bowel sounds are transmitted widely throughout the
5. Begin assessment at patient’s right and proceed to examine all 5 abdominal regions: abdomen, listening in one spot such as RLQ is usually sufficient
RUQ LLQ 5. report no bowel sounds when no significant sounds have been
RLQ Epigastric area recognized for 2 minutes.
LUQ Bowel sounds (normal, increased/decreased,
6. The exam technique sequence is as follows: absent)
Inspection àAuscultation àPercussion àPalpation Frequency
Character
INSPECTION IMPORTANT POINTS TO CONSIDER Bruits and friction rub (aorta, renal, iliac, femoral - listen on the epigastrium and in each upper quadrant, bruits confined
Peristalsis (increased/decreased peristaltic waves) - if you suspect for bowel obstruction (increased) arteries, costovertebral angles) to systole may be heard for pxs w/ high BP
- for very thin people peristalsis is normally visible - bruits in these areas that has both systolic and diastolic components
strongly suggest renal artery stenosis as the cause of HPN
Umbilicus (contour, location, inflammation, hernia)
Peritoneal rubs (RUQ or LUQ) - listen over the liver and spleen for friction rub
Striae (color: red, white, purple) - old silver striae or stretch marks are normal, while pink-
◦ friction rub in liver tumor, gonococcal infection around the liver,
purple striae may be associated to Cushing’s syndrome
splenic infarction
Hernias (abdominal, umbilical, incisional, diastasis
recti, epigastric, inguinal, femoral)
- Helps you to assess the amount and distribution of gas in the
Vascular changes: dilated veins - dilated veins of hepatic cirrhosis or of inferior vena cava
abdomen and to identify possible masses that are solid or fluid- filled
obstruction
- It can also be used to estimate the span of the liver and spleen
Lesions or rashes (areas of discoloration) PERCUSSION - In general, most of the areas of the abdomen are tympanitic when
Abdominal contour - bulging flanks of ascites percussed because of gas, but there are also scattered areas of
flat, scaphoid, protuberant, rounded - suprapubic bulge of a distended bladder or pregnant dullness from fluid and feces and solid organs such as liver and
bulging flanks/local bulges uterus or hernias spleen
symmetry - asymmetry from an enlarged organ such as liver and 4 quadrants (clockwise pattern)
visible organs or masses spleen or mass like lower abdominal mass of an ovarian or
Tympanitic/ dull - A protuberant abdomen that is tympanitic all throughout suggests
visible movement a uterine tumor
intestinal obstruction
Pulsation (increased/decreased pulsations) - normal aortic pulsation is frequently visible in the - Large tumor à dull to percussion and the air- filled bowel are
epigastrium displaced to the periphery
- increased pulsations of an aortic aneurysm or of increased
◦ Markedly distended bladder can be mistaken for such a tumor
pulse pressure - Dullness on both flanks prompts further assessment for ascites.
Scars (location, appearance) - you may describe or diagram the location
Spleen - Locate for the Traube’s space between a resonant lung above and
 Traube’s space the costal margin along the anterior axillary line. Normally, the sound
is tympanitic but when dullness in precussion is present, it detects the
presence of splenomegaly
Splenic percussion sign - Percuss the lowest interspace in the left anterior axillary line. This
area is usually tympanitic. Ask the px to take a deep breath and
percuss again.
- (+) splenic percussion sign is noted when a change of tympanitic to
dullness on inspiration is present, and this suggests splenomegaly
Liver - Use light to moderate percussion
- Begin with identifying the lower border of dullness in the MCL. Starting
from the level of the umbilicus with a tympanitic sound, percuss
upwards towards the liver until you first recognized a dull sound; this
marks your lower border of liver dullness.
- Next, establish an upper border of dullness starting from the nipple
line to make sure that u started on a resonant area, percuss
sequentially downwards towards the liver until you hear a liver
dullness.
- Now measure the distance between the 2 points, that is your vertical
span of liver dullness w/c is normally 6- 12 cm. You can also measure
the midsternal vertical liver span with the same steps but conducted
along the mid- sternal line.
- Decreased span of liver dullness: when air is present below the
diaphragm, perforated viscus, hepatitis or CHF
PALPATION
General palpation (areas of tenderness=facial !!!!!! Ask the px to point areas of tenderness and examine them lasts.
expression of Px, muscular resistance, superficial a. Light palpation
organs and masses) - Use pads of first three fingers of one hand and a light, gentle, dipping
Light palpation maneuver to examine abdomen
Deep palpation - Identify superficial organs or masses and any areas of tenderness or
increased resistance to your hand. If resistance is present, try to
distinguish voluntary guarding from involuntary muscular spasm
- Always observe the facial expression of the patient as this serves as
the most accurate assessment of abdominal tenderness.
b. Deep palpation
- Use palmar surface of fingers of one hand and a deep, firm, gentle
maneuver to examine abdomen (two hands, one on top of the other,
may be required if obesity or muscular resistance occurs
Peritoneal inflammation - Ask the px to cough and identify where the cough produces the pain.
When identified, map the area of tenderness
Rebound tenderness - Press down with ur fingers firmly and slowly, then withdraw then
quickly. Watch and listen to the px for signs of pain. Ask the px “which
one hurts more, when I press or when I let go?”
- If tenderness is felt elsewhere than where you were trying to eliicit the
rebound tenderness, that area may be the real source of tenderness.
Spleen - With your left hand, reach over and around the px to support and
press the lower left rib cage and adjacent soft tissue. With your right
hand below the left costal margin, press in towards the spleen. Begin
palpating low enough so can you palpate an enlarged spleen. Ask the
px to take a deep breath
Liver - With your left hand, place it behind the px supporting the right 11th
and 12th ribs and adjacent soft tissues. By pressing your left hand
forward, the px’s liver may be felt more easily by your right hand.
- Ask the px to take a deep breath or breath with their abd and plapate
the liver edge; note for any tenderness, normally: it is soft, sharp, with
smooth surface and slightly tender
Kidney - Usually not palpable
Aorta - Press firmly deep in the upper abdomen, slightly to the left of the
midline and identify the aortic pulsations
SPECIFIC TESTS
Ascites: shifting dullness/ fluid wave/ballottement Assessing possible ascites:
- Since the fluid seeks its own level, the dependent area is usually dull
in percussion while the gas filled bowel floats at the center percussion
gives a tympanitic sound.
- With px in supine postion, start percussing from an area of tympany at
the center going outward in several directions. Map the border
between tympany and dullness.
Confirming ascites:
Test for Shifting dullness:
- Turn the px onto one side, percuss and mark the boarders again. For
px w/o ascites, the previously marked areas of tympany and dullness
usually stay relatively constant.
- (+) shifting dullness is when the px changes position for supine to
lateral, areas of dullness shift to dependent areas.
Fluid Wave:
- ask the px or an assistant to press the edges of both hands firmly
down the midline of the abdomen.
- While you tap one flank w/ ur fingertips, feel on the opposite flank for
an impulse transmitted through the fluid.
Ballottement: identifying an organ or mass in an ascitic abdomen
- Straighten and stiffen the fingers of one hand together, place them

Appendicitis: Psoas sign, obturator sign,
Rovsing’s Sign
Peritoneal irritation: rebound tenderness
Acute cholecystitis: Murphy’s sign
Renal disease: Costovertebral Tenderness
on the abdominal surface and make a jabbing movement directly
toward the anticipated structure.
- This movt quickly displaces the fluid so that your fingers can directly
touch the surface of the structure through the abdominal wall.
Psoas sign:
- Pain on passive extension of the right thigh. Patient lies on left side.
Examiner extends patient's right thigh while applying counter
resistance to the right hip
- Anatomic basis for the psoas sign inflamed appendix is in a
retroperitoneal location in contact with the psoas muscle, which is
stretched by this maneuver
Obturator sign:
- Pain on passive internal rotation of the flexed thigh. Examiner moves
lower leg laterally while applying resistance to the lateral side of the
knee resulting in internal rotation of the femur
- Anatomic basis for the obturator sign inflamed appendix in the pelvis
is in contact with the obturator internus muscle, which is stretched by
this maneuver.
Rovsing’s sign:
- Press deeply and evenly in the LLQ, then quickly withdraw your
fingers.
- Pain in the RLQ during a left- sided pressure suggests appendicitis.
- Aka known as referred rebound tenderness
Same as above
- Hook fingers under costal margins on the right.
- Have the patient take deep breath.
- Sharp increase in tenderness with sudden stop in inspiration is
positive.
- Positive sign is indicative of gall bladder disease.
- Warn the patient what you are about to do.
- Have the patient sit up on the exam table.
- Use the heel of your closed fist to strike the patient firmly over the
costovertebral angles.
- Compare the left and right sides.
- Tenderness elicited suggest kidney infection such as pyelonephritis or
perinephric abscess.