The Abdominal Exam

A well-performed abdominal exam is one of the foundations of the complete physical. It is also one of the most difficult skills to master. 

 

Terminology

 

Review of General Anatomic Landmarks (surface anatomy)

 

Bowel Sounds

 

Exam Sequence
  1. Observe for contour, masses, symmetry.
  2. Listen for bowel sounds, then renal arteries, then iliacs, then femoral arteries. Be sure to listen before you touch the abdomen - by manipulating the abdomen, you can cause bowel sounds to appear, causing a false positive. This obviously defeats the purpose of listening for bowel sounds in the first place.
  3. Percuss for areas of dullness throughout entire abdomen, with specific attention to the left quadrants to confirm tympany - if you don't check for dullness, you may miss an enlarged spleen.
    Identify the stomach gas bubble, percuss liver span.
  4. Palpate, beginning with soft palpation, feeling for superficial masses or tenderness.
    Progress to deep palpation, feeling for masses throughout abdomen, looking for areas of tenderness.
    Palpate liver and spleen (you may be able to feel the liver, but should not be able to feel the spleen in a healthy patient).
    Palpate the aorta with both hands, applying firm pressure on either side, and checking for symmetric pressure on both hands.
    Thump on the back - place your flattened hand on the patient's back at the CVA, and strike your hand firmly with the side of your fist.

To aid in relaxation in patients who may have tense abdominal muscles or who are guarding, you can ask patients to flex their hips and rest the bottoms of their feet on the exam table (with knees bent). You can ask your patient to inhale deeply, and perform deep palpation during expiration. Finally, with patients who are having great difficulty relaxing, it may help to perform the initial part of the exam with your hand guiding the patient's hand (as if you were teaching the patient to perform the exam themselves), until the abdomen relaxes. 

Be sure to start low - typically at the level of the umbilicus - when both percussing and palpating for the liver and spleen. What you're really feeling for is a change in the firmness of the abdomen as your signal that you're palpating these organs. If they are enlarged and you begin to palpate too high, you won't feel a change in texture as you continue superiorly, since you will already be palpating the organ. So start low to make sure you don't miss the inferior margin (bottom edge).

If you suspect peritoneal signs will be present, as in appendicitis, there are numerous ways to elicit peritoneal signs without performing the classic rebound maneuver (pushing deeply then rapidly removing your hand). It is probably more humane to begin by trying to elicit the psoas sign, the obturator sign, or Rosving's sign. Alternatively, in patients with advanced disease, simply jiggling the bed with your hip will cause them discomfort.