learning objective: Given a simulated
patient with simulated symptoms, the student will be able to recognize
potential problems and properly perform the needed exam.
types of hernias.
organs and their position in the abdominal cavity.
different symptoms of an acute abdomen.
Medical Dictionary, 1989
The Merck Manual,
Examination of the Abdominal Region*
- Anatomy & Physiology
- The abdomen is divided into 4 quandrants.
- RUQ: right upper quadrant
- LUQ: left upper quadrant
- RLQ: right lower quadrant
- LLQ: left lower quadrant
- Normal palpable structures:
- Sigmoid colon: LLQ - firm, narrow tube
- Cecum and ascending colon: RLQ - a softer, wider tube
- Pulsationís of ascending aorta: midline in upper abdomen
- Less commonly palpable, but normal:
- Liver: just below right costal margin (*Costal- To a rib)
- Transverse and descending colon: RUQ & LUQ
- Lower pole of right kidney: RUQ deep, mostly in thin women
- Iliac artery: pulsationís - LLQ & RLQ
- Spleen tip: seldom felt - LUQ under ribs
- General principles of exam:
- Conditions required:
- Good light
- Relaxed patient
- Full exposure of abdomen
- Other helpful points on examination
- Should not have a full bladder.
- Supine position.
- Arms across chest, not above head.
- Ask patient where pain is, and examine last.
- If the patient is ticklish or frightened, initially use the patients
hand under yours as you palpate. When patient calms then use your hands to
- 6. Watch the patientís face for discomfort.
- Order of exam
- Auscultation - always perform before palpation
- Palpation: light & deep
- Inspection of the abdomen
- Contour: is abdomen flat, swollen or bloated? Is there an area that is
bulging or moving?
- Strai (stretch marks): a streak or line, may be red, white, or purple.
Dark pink-purple strai of Cushing disease.
*Cushing disease: Cushingís syndrome, in which the hypersecretion of
glucocorticoids is secondary to hypersecretion of adrenocorticotrophic
hormone from the pituitary (Tabers Medical Dictionary, 1989).
- Scars: location/appearence - describe or diagram their location.
- Venous: dilation - seen in hepatic cirrhosis or inferior vena cava
- Color: areas of discoloration or rashes.
- Umbilicus: contour, location, inflammation, hernia.
- Contour of abdomen
- Flat, rounded, protuberant or scaphoid.
- Bulging flanks - seen in ascites.
- Local bulges - pregnancy or distended bladder.
- Symmetrical - asymmetry with enlarged organs or masses.
- Visible organs or masses - lower abdominal masses of ovarian or
- Peristalsis: increased peristaltic waves of intestinal obstruction.
- Pulsation: increased pulsationís of aortic aneurysm.
*Aneurysm: Localized abnormal dilation of a blood vessel, usually an artery.
Due to congenital defect or weakness in the wall of the vessel.
*Hernia: Protrusion or projection of an organ or a part of an organ through
the wall of the cavity that normally contains it.
- Abdominal - hernia through the abdominal wall.
- Umbilical - bulging defect at umbilicus. Common in infants and
generally closes by 3 y/o.
- Incisional - defect in abdomen muscles after surgical incision. Must
palpate the size of the defect.
- Diastasis recti - not a true hernia, a separation or the two rectus
abdominus muscles. No clinical significance.
- Epigastric - small, midline protrusion through a defect in the linea
alba located between the xiphoid process and umbilicus.
- Auscultation of the Abdomen
- Bowel sounds (use diaphragm of stethoscope)
- Bowel sounds are widely transmitted throughout the abdomen. Listening
in one spot is usually sufficient.
- Normal sounds are due to peristaltic activity.
*Peristalsis: A pregressice wavelike movement that occurs involuntarily in
hollow tubes of the body.
- Normal sounds consist of clicks and gurgles.
- Hypoactive bowel sounds are less than 3-4 sounds a minute.
- Borborygmus - is the medical term for stomach growling. This is due to
prolonged episodes of hyperperistalsis. This is normal.
- Abnormal bowel sounds: caused by a number of illnesses. There are
several typically abnormal bowel sounds:
- High pitched tinkling: usually due to tension of air/fluid in a loop
of dilated bowel. This suggest obstruction.
- Rushes: If located at one area, usually are due to air fluid being
forced through small partially occluded lumen. This suggest partial
obstruction, especially if associated with concurrent abdominal activity.
- Hyperactive: Sometimes normal if combined with abdominal complaints,
can indicate early obstruction or GI bleed.
- Hypoactive or absent bowel sounds: Sometimes can be normal, but
combined with complaints can indicate paralytic ileus (a halt in
peristaltic activity due to extreme irritation from obstructive
peritonitis or unknown reasons).
- Bowel sounds cannot be said to be absent unless they are not heard
after listening for 3 minutes.
- Systolic Bruit: An adventitious sound of venous or arterial origin heard
on auscultation. Use bell of stethoscope.
- Listen at midline in middle of epigastrum for whooshing or blowing
systolic noise indicative of turbulent blood flow from arterial plaques or
aortic aneurysm. Important to listen for if patient has vascular
insufficiency of the lower extremities.
- Listen in bilateral costovertebral angles for renal artery bruits in a
hypertensive patient suggestive of renal artery stenosis.
*stenosis: Constriction or narrowing of a pasage or orifice (Tabers
Medical Dictionary, 1989).
- Listen over femoral areas for femoral artery bruits, in patients with
lower extremity vascular insufficiency.
- Venous Hum (rare) - epigastric/umbilical area.
- Soft humming noises with both systolic/diastolic component.
- Indicates increased collateral circulation between portal and venous
systems as in hepatic cirrhosis.
- Friction rubs (rare):
- Right and left upper quandrants
- Grating sound with respiratory movement
- Indicates inflammation of peritoneal surface of an organ.
- Succession splash:
- Splashing sound indicative of air or fluid in body cavity with shaking
individual: normal in s stomach.
- General Principles
- Technique as described in thorax/lungs.
- Percuss lightly in all quandrants.
- Assess areas of dullness and tympanny. Tympanny usually
- The Liver
- Percuss upward in right mid-clavicular line (MCL) from below
- Ascertain lower liver border dullness.
- Percuss from lung resonance downward on right MCL to ascertain upper
margin of liver dullness.
- Normally 6-12cm in right in right MCL.
- The Spleen
- Searching for the small area of dullness is seldom worthwhile unless
you suspect splenomegaly.
*Splenomegaly: Enlargement of the spleen (Tabers Medical Dictionary,
- Percuss in the lowest interspace in the left mid-axillary line. Have
the patient take a deep breath and hold. Repercuss the same area. Change
from tympanic to dull indicates splenomegaly.
- Percuss in several directions from resonance or tympanny toward
forward estimates area of splenic dullness to outline itís edges.
- Light palpation
- Gentle horizontal dipping motion with finger tips.
- Have the patient supine with knees slightly flexed.
- Identify muscular resistance and abdominal wall tenderness.
- Deep palpation
- Place one hand on top of the other. Press with outer hand and feel
with inner hand.
- Palpate tender areas last.
- Palpation of specific organs.
- Place left hand posteriorly parallel to and supporting 11th & 12th
ribs on right.
- Place right hand in upper quandrant well below area of liver
- Have the patient take deep breath and feel liver margin for
smoothness, firm sharp edge, and tenderness.
- An obstructed distended gall bladder may form an oval mass below the
edge of the liver t that merges with the liver edge.
- Start well below expected area of liver.
- Seldom palpable in normal adults. Causes include COPD, and deep
inspiratory descent of the diaphragm.
- Support lower left rib cage with left hand while patient is supine
and lift anteriorly on the rib cage.
- Palpate upwards toward spleen with finger tips of right hand,
starting well below left costal margin.
- Have the patient take a deep breath.
- Palpate for spleen as it descends.
- fA palpable spleen is almost always abnormal. Infectious
mononucleosis may cause splenomegaly.
*Mononucleosis: Presence of an abnormally high number of mononuclear
leukocytes in the blood (Tabers Medical Dictionary, 1989).
- Place left hand posteriorly just below the right 12th rib. Lift
upwards trying to displace the right kidney anteriorly.
- Palpate deeply with right hand on anterior abdominal wall.
- Have the patient take a deep breath.
- Feel for lower pole of kidney as it descends and try to capture it
between your hands.
- Have the patient release breath. Slowly release the kidney and feel
it slide back into place.
- Try the same on the left kidney, but is seldom palpable.
- Costovertebral angle tenderness (CVA tenderness)
- With patient seated upright, place palm of left hand over each
- Strike back of left hand with ulnar surface of right fist.
- Tenderness elicited suggest kidney infection such as
pyelonephritis or perinephric abcess.
*pyelonephritis: Inflammation of kidney substance and pelvis.
*perinephric abcess: Absess formation in the peritoneal membrane
surrounding the kidney (Tabers Medical Dictionary, 1989).
- Inguinal/Femoral areas
- Check bilateral inguinal areas for lymph node enlargement. Common
causes include: STD, Athletes foot, bug bites and lacerations/abrasions
to lower extremities.
- Palpate for femoral pulses.
- Check for inguinal and femoral hernias.
- Press deeply in upper abdomen slightly lateral to midline on both
- Assess width of aorta pulsations. Normal is 2.5cm in width, not
including abdominal wall thickness.
- Prominent pulsations with lateral expansion suggest an abdominal
- Evaluation of Acute Abdomen/Appendicitis
- Visceral (originating from the intra-abdominal organs)
- Usually dull quality
- Poorly localized
- Peritoneal irritation
- Sharp, severe, intense pain
- Localized to specific areas
- Coughing increases the pain
- Signs of peritoneal irritation in acute appendicitis
- Progression of pain
- Begins in umbilical area
- Localizes in right lower quandrant
- Guarding/muscular rigidity
- Voluntary guarding by tightness of muscle against palpation.
- b. Involuntary resistance, progressive abdominal rigidity. Patient
is unable to relax muscles. Bodyís protective function against pain.
- Localized tenderness - usually in RLQ or right flank pain.
- Rectal exam reveals right sided rectal tenderness. May indicate
inflammatory process other than appendicitis.
- Rebound tenderness
- Rovsingís sign (referred tenderness): tenderness/pain in RLQ during
left sided pressure.
- Referred rebound tenderness
- Psoas sign: An increase in pain from passive extension of the right
hip joint that stretches the iliopsoas muscle (Tabers Medical Dictionary,
- Place right hand above right knee of the patient.
- Have the patient flex right knee against resistance.
- Alternatively, have the patient turn to side, extend right leg at
- Pain with maneuvers suggests irritation of Psoas muscle.
- Obturator sign
- Flex patients right thigh at hip with right knee bent.
- Internally rotate the leg at the hip.
- Pain elicited suggest irritation of obturator muscle.
- Cutaneous Hyperesthesia: Increased sensitivity to sensory stimuli,
such as pain or touch.
- At a series of points down the abdominal wall, gently pick up skin
folds between finger and thumb without pinching the skin.
- Localized pain elicited in the RLQ may accompany appendicitis.
- Acute Cholecystitis: Inflammation of the gallbladder.
- RUQ pain and tenderness
- Murphyís sign: When the inflamed gallbladder is palpated by pressing
the fingers under the rib cage, deep inspiration causes pain because the
gallbladder is forced down to touch the fingers.
- 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 sign is indicative of gall bladder disease.
- Intra-abdominal mass vs. abdominal wall mass
- Have the patient tighten abdominal muscles wall.
- Mass in abdominal wall remains palpable where as intra-abdominal
mass will be obscured.
Hospital Corpsman Sickcall Screeners Handbook
Naval Hospital, Great Lakes
Operational Medicine 2001, Health
Care in Military Settings, NAVMED P-5139, May 1, 2001, Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington,