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Abdomen Physical

Examination
Objectives

Review anatomy of the abdomen.


Discuss the history for abdomen.
Discuss the criteria for abdominal
examination.
Demonstrate the physical
examination of abdomen.
Surface landmarks

Abd. Is a large oval cavity


Extend from diaphragm to brim of
pelvis
Bordered in the back by vertebral
column & paravertebral muscle
Front & side by ribs
Internal anatomy

Viscera: All internal organ


Solid viscera: liver, pancreas, spleen,
kidney.
Liver: filling the upper Rt Quaderent
(URQ)
Extend to Lt middclavicular line
Lower edge may be palpable
Internal anatomy

Hollow Viscera: stomach, gallbladder,


small intestine, colon, bladder
Usually not palpable
Spleen: posterolateral wall,
immediately under the diaphragm
Lies Obliquely behind & parallel to
10th rib lateral to midaxillary line
Width: 9-11 rib (7cm)- not palpable
Internal anatomy

Aorta:
Abdomen/ gastrointestinal system
ROS
Present history Problem with appetite,
weight gain, or loss,
change in bowel
habits, flatulence,
diarrhoea,
constipation, rectal
bleeding,
haemorrhoides, colour
of stools, abdominal
pain or discomfort,
nausea or vomiting.
ROS cont.
Past history surgery, trauma,
appendix, hernias,
Hx of jaundice,
hepatitis, liver
problems,
infectious
diseases, eg.
typhoid, family Hx
of cancer of bowel,
ulcers, prosthesis,
IUD, colostomy.
ROS cont.
Habits (ADL’s) Food habits, food
preferences, ethnic
or religious
restrictions, food
intolerances, fiber
in diet, bowel
habits problems,
laxatives, antacids,
aspirin use, alcohol
intake, lifestyle
factors.
Sample recording
Denies HX of G.I. disease, hepatitis,
CA bowel, digestion problems,
appetite “good”, bowels open daily.
Stated no flatulence, diarrhoea,
constipation, haemorrhoids, rectal
bleeding. Denies pain, use of
laxatives, aspirin and antacid. Eats 2
meals daily, “can’t take onions”. “Eats
lots of fiber daily”. Stool brown,
formed. “Drinks 2-3 glasses of wine
weekly”.
Preparation/ general approach

For good abdominal examination, you


need:
- good light
- relaxed patient
- full exposure of abdomen from
xiphoid process to the symphysis
pubis
Preparation cont.
Warm room
Empty the bladder
Supine position, pillow under the head
and knees bent
Arms at sides or across the chest
Warm stethoscope
Warm hands
Short fingernails
Preparation cont.

Examine tender or painful area last


Watch patient’s face for signs of
distress while examining
Approach slowly and avoid quick,
unexpected movements
Begin palpation with patient’s hand
beneath yours for frightened or
ticklish patients
Steps of abdominal examination

Inspection

Auscultation

Percussion

Palpation
Reasons for this sequence

Palpation disturb bowel sounds,


increase peristalsis which would give
a false interpretation of bowel sounds

Palpation is most invasive, leave it till


the end
Inspection
Skin - scars, striae, dilated veins, rashes,
lesions
Umbilicus - contour, location, signs of
inflammation, hernia
Contour - flat, rounded, scaphoid,
protuberant
Symmetry - visible masses or organs
Peristalsis - may be visible in very thin
person
Pulsation - normal aortic pulsation is
visible in the epigastrium
Breathing - abdominal in males and
thoracic in females
Auscultation
Listen to bowel sounds with diaphragm
Begin at RLQ because bowel sounds are
always present here normally
Note the character and frequency of bowel
sounds
Bowel sounds are high pitched sound
occurring irregularly anywhere from 5-30
times/ minute
Listen for 5 minutes before deciding
absence of bowel sounds completely
Auscultation cont.

Listen for vascular sounds or bruits

Use the bell

Check over the aorta

Usually no such sound is present


Percussion

General percussion
Percuss all quadrants - tympany
Liver span
Measure the height of liver in Rt.
Midclavicular line
Start from resonance to dullness
and from tympany to dullness
Normal liver span in adult is 6-12 cm
Percussion cont.
Spleen
Can be located from 9th to 11th
intercostal space just behind Lt.
midaxillary line
Costovertebral angle tenderness
(CVA)
Indirect fist percussion causes the
tissues to vibrate instead of producing
sound - assess the kidneys
Percussion

Assess the amount and distribution of


gas in the abdomen

Identify possible masses that are solid


or fluid filled

Estimate the size of the liver and


spleen
Palpation

Check size, location, consistency of


certain organs

Screen for an abnormal mass or


tenderness

Identify muscular resistance


Palpation cont.
Aorta

Light palpation

Deep palpation (bimanual)

Organ palpation

Rebound test
Palpation cont.

Aorta

Better to palpate aortic pulsation


before percussion to rule out
abdominal aortic aneurysm (AAA)

Normally it is 2.5 to 4 cm wide in adult


and pulsates in an anterior direction
Palpation cont.
Light palpation
Impression of the skin surface and
superficial musculature
Palpate with pad of fingers
Depress the skin about 1 cm
Make a gentle rotary motion
Lift the fingers, don’t drag them
Move clockwise to the next location around
the abdomen
Palpation cont.
Deep palpation
Use the same technique
Push down about 5-8 cm
Use a bimanual technique to overcome the
resistance of a very large or obese
abdomen
Place hands on top of each other (top hand
push, bottom hand feel)
Note the location, size, consistency,
mobility of any palpable organ
Note presence of abnormal enlargement,
tenderness or masses
Palpation cont.
Liver palpation
Use two hands (one under the back at
11th & 12th rib to support the
abdominal contents, one on RUQ)
It is normal to feel the edge of the
liver
Spleen palpation
Use same technique except that one
hand placed on LUQ
Normally not palpable
Palpation cont.

Rebound test
Use one hand
Hold hand 90 degree, push down
slowly and deeply then lift up quickly
This makes structures that are
indented by palpation rebound
suddenly
A normal or negative response is no
pain on release of pressure
Palpation cont.
Organs frequently Organs usually not
palpable palpable
Liver edge (on Spleen
inspiration)
Left kidney
Right kidney (lower
pole)
Gallbladder
Abdominal aorta Pancrease
Descending colon & Stomach
sigmoid Small intestine
Ascending colon Transverse colon.
Bladder when
distended
Recording objective data
Round, symmetrical abdomen. Loose
muscle tone. No lesions, rashes, scars or
discolouration. Bowel sounds audible in all
quadrants, no bruits noted. Aortic pulsation
is anterior, no lateralization of pulse.
Tympanic on percussion, liver span is 10
cm. Splenic dullness at 10th intercostal
space in Lt midaxillary line. Abdomen soft,
no tenderness, no masses, no rigidity.
Liver and spleen not palpable. No rebound
tenderness. No CVA tenderness. No
lymphadenopathy or hernias.