Abdomen Assess the abdominal contour by standing to the persons right side and looking down.

Then stoop or sitwith your head slightly above the abdomento gaze across it. Determine the profile from the rib margin to the pubic bone. The contour normally ranges from flat to rounded. Abnormal findings Scaphoid abdomen Protuberant abdomen (distention) To assess symmetry, shine a light across the persons abdomen. The abdomen should be symmetrical bilaterally and display no bulges, masses, or asymmetry. To highlight any change, ask the person to take a deep breath or do a sit-up without using the hands. You should see no localized bulging. Abnormal findings Note any localized bulging, masses Hernia-protrusion of abdominal visceral through abnormal opening in muscle wall Hernia-enlarged liver or spleen may show Next, inspect the umbilicus. Normally, it is midline and inverted, with no discoloration, inflammation, or hernia. Abnormal findings Everted with acites, or underlying masses Deeply sunken and obesity Enlarged and everted with umbilical hernial Bluish periumbilical color occurs with intraabdominal bleeding (Cullen's sign) Then inspect the skin. It should have a smooth, even surface, with a homogeneous color and no rashes or lesions. Veins should not be visible unless the person is thin. Note any surgical scars. Abnormal finding Redness with localized inflammation Cutaneous angiomas(spider nevi) occur with portal hypertension or liver disease Prominent, dilated veins occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction. Veins are more visible with malnutrition due to thinned adipose tissue Poor turgor occurs with dehydration, whch often accompanies GI disease Also, observe for pulsations or movement in the abdomen. You may see respiratory movement. In a thin person, you may also see aortic pulsations in the epigastric area. Abnormal findings Marked pulsation of the aorta occurs with widened pulse pressure (hypertension, aortic, insufficiency, thyrotoxicosis) with aortic aneurysm

 Marked visible peristalsis together with a distended abdomen, indicates intestinal obstruction To conclude inspection, note the pattern of pubic hair growth, which should be appropriate for the persons age and sex, and observe the persons demeanor, which should be comfortable and relaxed. Abnormal findings Patterns alter with endocrine or hormone abnormalities and with chronic liver disease Restlessness and constant turning to find a comfortable position occur with colicky pain of gastroenteritis or bowel obstructions Absolute stillness, resisting and movement occurs with pain of peritonitis Knee flexed up, facial grimacing and rapid, uneven respirations also indicate pain To auscultate the abdomen, begin with bowel sounds because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. After warming the diaphragm of the stethoscope, hold it lightly against the skin. Start in the RLQ over the ileocecal valve, because bowel sounds should always be present here normally. Note the character and frequency of bowel sounds. Bowel sounds originate from the movement of air and fluid through the small intestine. which typically are high-pitched, gurgling, cascading sounds that occur intermittently 5 to 30 times per minute. Do not count the bowel sounds, but determine if they are normal, hyperactive, or hypoactive. One type of hyperactive bowel sounds are fairly common. Hyperperistalis when you feel your stomach growling borborygmus. Silent abdomen is uncommon, must listen for 5 minutes by you watch before deciding bowel sounds are completely absent. Abnormal findings Hyperactive bowel sounds are loud, continuous, high-pitched, rushing, and tinking sounds that signal increased motility. Hypoactive bowel sounds are diminished or absent and occur after abdominal surgery or with peritoneal inflammation. Next, auscultate for vascular sounds (or bruits). Using firmer pressure, listen over the aorta as well as the renal, iliac, and femoral arteries. You should hear no vascular sounds. Abnormal findings Note location, pitch and timing of a vascular sounds A systolic bruit is a pulsatile bowling sound and occurs with stenosis or occlusion of an artery Venous hum and peritoneal friction rub are rare After warming your hands, use percussion to assess all four quadrants. As you do, note: areas of tympany (indicating gas). and areas of dullness (indicating fluid, adipose tissue, or feces). Normally, tympany predominates. Abnormal findings

 A large area of dullness may suggest an enlarged organ, distended bladder, adipose tissue, fluid or mass Hyperresonance is present with gaseous distention Now measure the liver span through percussion down the right midclavicular line. Begin over the lungs and percuss down the intercostal spaces, until the sound changes from resonance to dullness. Mark the spot, which is usually in the fifth intercostal space. Then percuss up the midclavicular line, beginning over the abdomen. Note where the sound changes from tympany to dullness. Mark this spot, which is normally at the right costal margin. Then measure the distance between the two marks. Typically, it ranges from 6 to 12 centimeters. Hight of the liver span correlates with the hight of the person. Taller person have longer livers and males have larger liver span than females of the same height. Mean liver span is 10.5 cm for male and 7 cm for females. Abnormal findings Enlarge liver span indicates liver enlargement or hepatomegarly Accurate detection of liver orders is confused by dullness above the 5th intercostal space, which occurs with lung disease, pleural effusion or consolidation Accurate detection at the lower border is confused when dullness is pushed up with ascites or pregnancy or with gas distention in colon, which obscures lower border. If the person has abdominal distention or tense abdominal muscles, use the scratch test to check the liver span. Place the stethoscope over the liver. With one finger, scratch in short strokes over the abdomen, from the RLQ up toward the liver. When the scratching sounds louder, youve reached the border from one a hollow organ to a solid one. Next, assess the spleen by percussing down the left midaxillary line. If stomach tympany doesnt obscure the spleen, you should hear splenic dullness from the 9th to 11th intercostal spaces. Now percuss in the lowest intercostal space in the left anterior axillary line. Area of splenic dullness normally is not wider than 7cm in the adult and should not encroach on eh normal tympany over the gastric air bubble. You should hear tympany. Percuss in the lowest interspace in the left anteior axillary line. Ask person to takes a deep breath. Tympany should remain through full inspiration, showing a lack of splenic enlargement. Abnormal finding Dull note forward of the midaxillary line indicates enlargement of the spleen Trauma, mononucleosis, infection Anterior axillary line, a change in percussion from tympany to a dull sounds will full inspiration is a positive spleen percussion sign, indicating splenomegaly. This method will detect mild to moderate splenomegaly before the spleen becomes palpable, as in mononucleosis, malaria, or hepatic cirrhosis Costovertebral Angle Tenderness to assess the kidneys, use indirect fist percussion. For this assessment, place one hand over the 12th rib at the costovertebral angle, and thump it with the ulnar edge of your other fist. The person should feel a thud, but no pain.

Abnormal findings Sharp pain occurs with inflammation of the kidney or paranephric area

Fluid Wave Standing on the persons right side and place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen in the midline. Place your left hand on the person's right flank. Right hand reach across the abdomen and give the left flank a firm strike. If ascities present, the blow will generate a fluid wave through the abdomen an you will feel a distinct tap on your left hand If abdomen is distended from gas or adipose tissue, feel no change Abnormal findings Ascities occurs with HF, portal hypertension, cirrhosis, hepatitis, pancretities and CA Positive fluid wave test occurs with large amounts of ascitis fluid Shifting Dullness 2nd test for ascities is percussing for shifting dullness. Supine person, ascities fluid settles by gravity into the flanks, displacing air-filled bowel movement. Hear tympany note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid. Percuss down the side of abdomen, if fluid is present, the note will change from tympany to dull as you read its level. Turn person onto right side, fluid will gravitate to the dependent side, displacing the lighter bowel upward. Percuss upper side of abdomen and move downward. The sound change from tympany to dull as you reach the umbilicus. Abnormal findings Shifting dullness is positive with a large volume of ascitic fluid. Will not detect fluid less than 500ml

Perform palpation to judge the size, location, and consistency of certain organs and to screen

for abnormal mass or tenderness. Before palpating the abdomen 1.promote muscle relaxation by bending the persons knees and helping him or her relax. 2. Keep your palpation hand low and parallel to the abdomen 3. Teach the person to breathe slowly(in through the nose and out the the mouth 4. Keep you own voice low and soothing. Conversation may relax the person 5. Try emotive imagery 6. With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate people are not ticklish to themselves 7. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. You can slide the stethoscope out when the person is used to being touched Then with warm hands, begin light palpation in each quadrant, keeping your hand low and parallel to the abdomen. With your fingers close together, lightly press in about 1 centimeter. Make gentle rotary motions, sliding the fingers and skin together. Then lift the fingers and move clockwise to the next location. Purpose here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. You may feel voluntary muscle guarding, but you should not detect rigidity, masses, or tenderness. Abnormal findings Muscle guarding, Rigidity, large masses, tenderness. Involuntary rigidity is a constant boarding like hardness of the muscles. Protective mechanism accompanying acute inflammation of the peritoneum Unilateral and the same area usually becomes painful when the person increase intraabdominal pressure by attempting a sit-up Next, palpate deeply in all quadrants. Use the same technique you used for light palpation, but press in about 5 to 8 centimeters. If the person has a very large or obese abdomen, use bimanual palpation. Place one hand on top of the other. Then push with the top hand and palpate with the relaxed bottom hand. Note location, size, consistency, and mobility of any palpable organs and present of abnormal enlargement, tenderness, or masses. To make sense of what youre palpating, visualize the structures under each quadrant. And, dont mistake a mass for a normally palpable structure, such as the: xiphoid process, liver edge, lower pole of the right kidney, aorta, rectus muscle edges, sacral promontory, cecum, sigmoid colon, pregnant uterus, or full bladder. As you palpate, note the location, size, consistency, and mobility of any palpable organs. Also note any abnormal enlargement, tenderness, or masses. Mild tenderness is normal when palpating the sigmoid colon. Abnormal findings Tenderness occurs with local inflammation, with inflammation of the periteoneum or underlying organ, and with an enlarged organ who's capsule is stretched.

Now, palpate for the liver. To support the abdominal contents, place your left hand under the

11th and 12th ribs and lift up. With your fingers parallel to the midline, place your right hand on the persons RUQ. Push down deeply and under the right costal margin. Ask the person to take a deep breath as you palpate. If the liver is palpable, its firm, smooth edge should bump your fingertips during inhalation. Abnormal findings Expect with a depressed diaphragm, a liver palpated more than 1 or 2 cm below the right costal margin is enlarged. Record the number of centimeter in descends and note it consistency and tenderness. As an alternative, you can palpate the liver with the hooking technique. While standing at the persons shoulder and facing the feet, hook your fingers over the costal margin. As the person takes a deep breath, feel for liver edge to bump against your fingertips. To palpate for the spleen, reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift up for support. With your fingers pointed toward the axilla, place your right hand obliquely on the left upper quadrant just below the rib margin. Push your hand deeply down and under the left costal margin. Then, ask the person to take a deep breath. Normally, the spleen is not palpable. When enlarged, the spleen bumps your fingertips during inhalation.It can grow so large that it extends into the lower quadrant. Abnormal findings Spleen enlarged with mononucleosis and trauma If you feel enlarged spleen, refer the person but do not continue to palpate it Enlarged spleen is friable and can rupture easily with over palpation As an alternative, roll the person onto the right side to displace the spleen forward and down. Then palpate the spleen, using the same basic technique. Next, palpate the kidneys. For the right kidney, put your hands in a duckbill position at the right flank. As you press your hands together firmly, ask the person to inhale deeply. In most people, you will feel no change or you may feel the bottom of the right kidney as a round, smooth mass. For the left kidney, reach your left hand across the abdomen and behind the left flank for support. Then push your right hand deep into the abdomen and ask the person to breathe deeply. In adults, the left kidney should not be palpable. Left kidney sits 1 cm higher than the right kidney and is not palpable normally. Abnormal findings Enlarged kidney, kidney mass To palpate the aorta, place your thumb and fingers on the upper abdomen slightly left of midline and palpate lightly. The aortic pulsation normally is 2.5 to 4 centimeters wide and pulsates anteriorly. Abnormal findings Widened with aneurysm Prominent lateral pulsation with aortic aneurysm If needed, perform two special procedures. For someone who reported abdominal pain or

tenderness, check for rebound tenderness (or Blumbergs sign). Hold your hand perpendicular to the abdomen, away from the painful area. Push down slowly and deeply; then lift up quickly. Normally, this action causes no pain. If you elicit pain or rebound tenderness, Blumbergs sign is present, indicating peritoneal inflammation. Abnormal findings Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation Peritoneal inflammation accompanies appendicities If liver palpation caused pain, check for inspiratory arrest (or Murphys sign). Hold your fingers under the liver border as the person inhales deeply. If the person feels sharp pain and abruptly stops inhaling, Murphys sign is present, which suggests an inflamed gallbladder. Abnormal findings When the test is positive, as the descending liver pushes the inflamed gallbladder onto the examining hand, the person feels sharp pain and abruptly stops inspiration midway Iliopsoa's Muscle test Perform this muscle test when acute abdominal pain of apprendicitis is suspected. Person supine, lift the right leg straight up, flexing at the hip; then push down over the lower part of the right thigh as the person tries to hold the leg up. Negative test, person feels no change Abnormal findings Iliopsoa's muscle is inflamed, pain is felt in the RLQ Obturator Test This test performed when appendicities is suspected. Person supine, lift the right leg, flexing at the hip and 90 degrees at the keep. Hold the ankle and rotate the leg internally and externally. Negative test, person feels no pain. Abnormal findings Perforated appendix irritates the obturator muscle producing pain Common Sites of Referred Abdomen Pain Liver- Hepatitis may have mild-to-moderate, dull pain in RUQ or epigastrium along with anorexia, nausea, malaise, low-grade fever. Esophagus-GERD is complex of symptoms of esophagitis, including burning in mildepigastrium or behind lower sternum that radiates upward or heartburn. Occurs 30 to 60 min after eating, aggrevated by lying down or bending over Gallbladder-Sudden pain in RUQ that may radiate to left and right scapula, and which builds over time, lasting 2-4 hours, following ingestion of fatty foods, ETOH or caffeine Associated with nausea and vomiting and positive Murphy's sign or sudden stop in inspiration with RUQ palpation Pancreas-Pancreatitis has acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank, severe nausea, and vomiting Duodenum-Duodenal ulcers typically has dull, aching, gnawing pain, does not radiate, may

be relived by food and may awaken the person from sleep Stomach- Gastric ulcer pain is dull, aching, gnawing, epigastric pain, usually bought on by food, radiating to back or substernal area. Sudden onset that refers to one or both shoulders Appendix- Apprendicities typically starts as dull, diffuse pain in periumbilical region that later shifts to sever, shape, persistent pain and tenderness localized in RLQ. Pain is aggravated by movement, coughing, deep breathing, associated with anorexia, then nausea and vomiting. Kidney- Kidney stones prompt a sudden onset of serve, colicky flank or lower abdominal pain Small intestine- Gastroenterities has diffused, generalized abdominal pain, with nausea, diarrhea Colon-Large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen, bloating. Irritable bowel syndrome (IBS) has a sharp or burning, cramping pain over a wide area. Does not radiate. Bought on by meals, relived by bowel movement. Abdominal Distention Obesity-Uniformly rounded, umbilicus sunken, normal bowel sounds, tympany, scattered dullness over adipose tissue, normal palpation, may be hard to feel through thick abdominal wall. Air or Gas- Single, rounded curve, everted umbilicus, bulging flanks when supine. Taut, glistening skin, recent weight gain, increase in abdominal girth. Normal bowel sounds over intestines, diminished over ascitic fluid. Tympany at top where intestinal float. Dull over fluid. Produces fluid wave and shifting dullness. Palpate taut skin and increased intraabdominal pressure limit palpation. Pregnancy- Single curve, umbilicus protruding. Breast engorged. Fetal heart tones. Bowel wounds diminished. Tympany over intestines. Dull over enlarging uterus. Feces-Localized distention. Normal bowel sounds, tympany predominates, scattered dullness over fecal mass, palpation plastic or ropelike mass with feces in intestines Ovarian Cyst (Large)-Curve in lower half of abdomen, midline, everted umbilicus. Normal bowel sounds over upper abdomen where intestines pushed superiorly. Percuss top dull over fluid wave and shifting dullness. Large cyst produces fluid wave and shifting dullness. Palpate Transmits aortic pulsation while ascites does not. Tumor-Localized distention, normal bowel sounds, percuss dull over mass if reaches up to skin surface, and palpate define borders. Distinguish from enlarged organ or normally palpable structure. Abnormalities on inspection Umbilical Hernia- soft, skin-covered mass, which is the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical right. Common in black, chinese and premature infants Epigastric Hernia-small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing. Incisional Hernia-bulge near an old operative scar that may not show when person is supine but is apparent when the person increases intraabdominal pressure by a sit-up, stand or Valsave maneuver. Diastasis Recti- midline longitudinal ridge, separation of the abdominal rectus muscle. Ridge is revealed when intraadominal pressure is increased by raising head while supine. Abnormal bowel sounds Succussion Splash-Unrelated or peristalsis this is a very loud splash auscultated over the

upper abdomen. Increase air, fluid in the stomach as seen with pyloric obstruction or large hiatus hernia. Hypoactive bowel sounds-Diminished or absent bowel sounds signal decreased motility due to inflammation as seen with peritonitis from paralytic ileus as following abdominal surgery or from late bowel obstruction. Hyperactive bowel sounds-Loud, gurgling sounds,''borboygmi, signal increased motility. Early bowel obstruction (high-pitched) gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus. Abnormal on palpation Enlarged Organs Enlarged Liver-Enlarged, smooth, and nontender liver occurs with fatty infiltration, portal obstruction or cirrhosis, hight obstruction of inferior vena cava, and lymphocytic leukemia. Tender to palpate Enlarged Nodular liver- occurs with late portal cirrhosis, metastatic cancer or tertiary syphilis Enlarged Gallbladder-tender, suggests acute cholcystitis. Feel it behind the liver border as smooth and firm mass like a sausage. Difficult to palpate due to involuntary rigidity of abdominal muscle. Exquisitely painful to fist percussion. Enlarged Spleen-Superiorly is stopped by the diaphragm, the spleen enlarges down to the midline. Splenomegaly occurs with acute infections (mononucleosis), it is moderately enlarged and soft with rounded edges. Chronic enlargement is firm or hard, with shape edges. Enlarged spleen is usually not tender to palpate. Enlarged kidney- hydronephrosis, cyst, or neoplasm. May be difficult to distinguish an enlarged kidney from an enlarged spleen because they have similar shapes. Both extend forward and down. Percuss over kidney is tympanic and spleen is dull. Aortic Aneurysm- More than 95% are located below the renal arteries and extend to the umbilicus. Feels like pulsation mass in the upper physical examination and feel like a pulsation mass in the upper abdomen just to the left of midline. Can hear a Bruit, femoral pulses are present by decreased.