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GENERAL RULES:

Wash hands / warm them.

Patient should be lying flat.

Keep the room as warm as possible and make sure that the
lighting is adequate.

Proceed calmly / dont make sudden moves.

Approach from right side of the patient.

Gather as much data as possible by observation first.

Arms at side (behind head tightens abdomen) & legs straight.

If the head is flexed, the abdominal musculature becomes tensed

and the examination made more difficult

Bending knees may relax abdomen.

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Abdomen should be fully exposed. Patient needs to be

exposed from above the xiphoid process to the symphysis
pubis. Exposure:---

1. Ask the patient to lie on a level examination table that is at a

comfortable height for both of you. At this point, the patient should
be dressed in a gown and, if they wish, underwear.
2. Take a spare bed sheet and drape it over their lower body such that
it just covers the upper
edge of their underwear (or
so that it crosses the top of
the pubic region). This will
allow you to fully expose
the abdomen while at the
same time permitting the
patient to remain somewhat
covered. The gown can then
be withdrawn so that the
area extending from just
below the breasts to the
pelvic brim is entirely
uncovered, remembering that the superior margin of the abdomen
extends beneath the rib cage.

Order of Examination

Inspection
Auscultation
Percussion
Palpation

Inspection

: standing at the foot of the table and looking

up towards the patient's head

1. Abdominal contour(Appearance of the abdomen )Shape=contour:

Is it flat? Distended? If enlarged, does this appear
symmetric or are there distinct protrusions, perhaps
linked to underlying organomegaly? The contours of
the abdomen can be best appreciated by standing at
the foot of the table and looking up towards the
patient's head. Global abdominal enlargement is
usually caused by air, fluid, or fat. It is frequently
impossible to distinguish between these entities on
the basis of observation alone, distended with full

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flanks. 5F
are the causes of abdominal
distentin fat, feces ,flatus ,feotus , fluid.
2.
Abdominal skin --Scars , striae (purple or
silver), dilated veins around umbilicus in caput
medusa veins radiating from the umbilicus & its
direction of flow: from below upward or vise versa
((portal hypertension)) and veins in the lateral
parts
of
abdomen
((
inferior
vena
cava
obstruction))
,rashes and lesions, Peristalsis
(visible--Visible loops of bowel) ,Pulsations (Aorta).
The abdomen is divided into 9 quadrants by two vertical midclavicular
lines and two horizontal linesone through transpylorus and the other
through the anterior iliac spine.

Common scars:
1. Right subcostal scar---- cholycestectomy scar
2. Mid line long lapratomy scar---- acute abdomen of surgical
unknown cause
3. Right or Left lumbar scar---- kidney surgical intervention
4. Suprapubic scar---- Caesarean scar or prostate operation or
pelvic operation.
5. Mid line supra umbilical scarduodenal ulcers , pancreatic
operations.

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Respiratory movement :
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Male
--- abdomino-thoracic-respiration.
Female thoraco-abdominal-respiration.
4.

manner
the

of

manner

breathing
of

is

breathing

abdominal
is

thoracic

Umbilicus central or pushed down , inverted or flat or everted.

The flat umbilicus is a clue to the ascitis or organomegally due to

increase intraabdominal presure.

Look for discoloration over the umbilicus:

1. Cullens Sign: discoloration over the umbilicus.

2. Grey Turners Sign: discoloration over the flanks.

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These are both late signs suggesting intra-abdominal bleeding.

SUMMARY:

INSPECTION
Shape of the abdomen and flanks
Skin scar
peristalsis

,striae

,prominent

veins

,umbilicus

visible

Movements of abdominal wall with respiration

Ask the patient to cough and look for hernial orifices
Hernia is derived from the Latin for "rupture"
It is the protrusion of an organ or part of an organ through a
defecte in the wall of the cavity ((peritoneal lining ))normally
containing it.
Types of herniae:
Inguinal (( Indirect or indirect ))
Inguinal hernias can be direct which is herniation through an area
of muscle weakness, in the inguinal canal, and inguinal hernias
indirect herniation through the inguinal ring. Indirect hernias, the
more common form, can develop at any age but are especially
prevalent in infants younger than age . This form is three times
more common in males.
Femoral Herniation through the femoral canal .
Incisional Herniation ------- through an area weakened by a scar
Umbilical
Paraumbilical --------umbilicus

Acquired defect above or below the

Epigastric --in the midline of abdomen above the umbilicus

caused by a defect in linea alba.
If there is a visible mass or herniae , you have to asses the :

Size

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Site
Surface
Shape
Affect of cough

Palpation:

Kneel down
Ask about site of abdomenal pain

First warm your hands by rubbing them together before

placing them on the patient. The pads and tips (the most
sensitive areas) of the index, middle, and ring fingers are the
examining surfaces used to locate the edges of the liver and
spleen as well as the deeper structures. You may use either
your right hand alone or both hands, with the left resting on
top of the right.put the palm of your right hand over abdomen
and flexes your hand frequently at metacarpophalangeal and
interphalangeal joints.

Apply slow, steady pressure, avoiding any rapid/sharp

movements that are likely to startle the patient or cause
discomfort.

Examine each quadrant separately, imagining what structures

lie beneath your hands and what you might expect to feel.

A. SUPERFICIAL PALPATION:
Aim to get confidence and assurance , to check
temperature ,tenderness.
Palpate the abdomen to detect:
1. Tenderness
Rigidity

2.Muscular rigidity or
3.Superficial organs and
masses

Before you begin palpation, ask your patient if he has any

pain or tenderness ,
and be away from the area of the pain . Palpate that
area last, using gentle pressure.

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Start
your
palpation by the
palm of the right
hand from the
right iliac fossa
and go anti-clock
wise .
From
RIF
to
suprapubic left
iliac fossa left lumbar---- left hypochondrial --- epigastric
-----right hypochondrial----right lumbar.. Press down around 1
cm

Light palpation by moving your hand slowly and just lifting

it off the skin.
Watch for patients face for signs of discomfort.
Abdominal pain upon light palpation suggests peritoneal
irritation or inflammation
If rigidity or guarding while palpating, determine whether
it is voluntary (patient anticipates the pain) or involuntary
(peritoneal inflammation)
Assess for rebound tenderness by pushing slowly and then
releasing your hand quickly off the tender area.
Watch for patients face for signs of discomfort.
Identify any masses and note:
Size,Location,Contour,Tenderness,Pulsations,Mobility
DEEP PALPATION:
For the organs and masses.
A deeper exam is performed with the right

hand or two hands, one on top of the other

again flexing at the MCP & IPJ joints. You should still be looking at the patients face for
them flinching due to pain. Again, examine all 9 named segments of the abdomen.

Liver is located under right upper quadant and if the liver enlarged
or pushed it descend toward the right iliac fossa along the mid
calvicular line.
In general, it is easier to detect abnormality if you start in an area
that you're sure is normal by comparison.
The right iliac fossa is the starting point for superficial and deep
palpation.

Direction of enlargement of organs

Liver: Enlarges towards right lower quadrant

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Spleen: Diagonally towards right lower quadrant

Reactions that may indicate pathology include:

Guarding, describing muscle contraction as pressure is applied.

Rigidity, indicating peritoneal inflammation.

Rebound, pain on release

Hernial orifices if positive cough impulses.

Start by kneeling down to be on the same level of patients abdomen.

Start the deep palpation by putting your right hand (palm) over the
abdomen of the patient.
start from right iliac fossa and ascend
through mid clavicular line toward right hypochondrial area . keep your
palm in touch with the patients abdomen.
One way..Gently push down (posterior) and towards the patient's head
with your hand oriented roughly parallel to the rectus muscle or lower
right costal margin, allowing the greatest number of fingers to be
involved in the exam as you try to feel the edge of the liver. Advance your
hands a few cm cephelad and repeat until ultimately you are at the
bottom margin of the ribs.

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Pushing up and in while the
patient takes a deep breath
may make it easier to feel
the liver edge as the
downward movement of the
diaphragm will bring the
liver towards your hand.
The tip of the xyphoid
process, the bony structure
at the bottom end of the
sternum, may be directed
outward or inward and can
be mistaken for an
abdominal mass. You should
be able to distinguish it by
noting its location relative
to the rib cage (i.e. in the
mid-line where the right and
left sides meet).

The two handed

method may be used. Begin at the right lower quadrant and examine the entire abdomen gently
by deep palpation.

Lay one hand over the abdomen and push with the second concentrating on the feel of the
bottom hand. Once again, known tender areas should be palpated last.

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Usual way----1.Start from right iliac fossa with your hand( palm ) parallel to the right costal margin
2.Ask the patient to take deep breath while keeping your hand in touch
3.Ask the patient to exhale , palpate deeply 4 cm in as the abdomen become relaxed
4.Preeced toward the right costal margin through midclavicular line
5. During expiration, palpate deep. During inspiration, moves toward RT costal margin till
you fell the liver margin where you have to ask the patient to take deep breath and go
deeply with your hand 4cm depth. This is because the liver is intraperitoneal and moves
down with inspiration.

For spleen:

The Palpation of the spleen is as for the liver but in the direction of the
left hypochondrium. The edge of the spleen which may be felt if distended is more
nodular than the liver.

The normal spleen in not palpable. When enlarged, it tends to grow towards the
pelvis and the umbilicus (i.e. both down and across)
Another way to assess for splenomegaly is to ask the patient to lie on their right
side.

Support the rib cage with your left hand and again ask the patient to take

deep breaths in moving your right hand up towards the left hypochondrium.

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Spleen (if not

palpable, R lateral
decubitus)--- The
edge, when palpable,
is soft, rounded, and
rather superficial

To feel
for the
kidneys
you
should place one hand under the
patient in the flank region ((right hand
at the inferior and lateral border
of the ribs))and the other hand on top.
---pushing down as you push

up from behind with your left

hand.-----You should then try to
ballot the kidney between the two
hands. In the majority of people the
kidneys are not palpable, but they may
be in thin patients who have no renal
pathology.

Note:
If the liver is palpable , it may be pushed down or enlarged. Liver span is
the next step to be done.
If the spleen is palpable , it is enlarged.
If the liver is palpable , it is important to detect the tenderness--hepatitis or congestion, the size below the costal margin(cm)
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,consistencyfirm or hard, edge ,surface regularity---nodular /

irregular in malignancy or secondaries , pulsatile tricuspid
regurgitation .

You can also try to "hook" the

edge of the liver with your
fingers. To utilize this
technique, flex the tips of the
fingers of your right hand (clawlike). Then push down in the
right upper quadrant and pull
upwards (towards the patient's
head) as you try to rake-up on
the edge of the liver. This is a
nice way of confirming the
presence of a palpable liver
edge felt during conventional examination.

Causes of hepatomegally:
1. Infections--- hepatitis HAV , HBV ,HCV, EBV, CMV , TB abscess , malaria
,alcohol
2. Inflammtion ---- autoimmune hepatitis
3. Ischemia----- bubb chiari syndrome , congested liver ,hepatic vein
thrombosis
4. Tumour ---- hepaoma , lymphoma , leukemia
5. Tumour 2ry--- metastases
6. TB------ abscess
7. Fatty liver

Causes of splenomegally ( huge):

4 fingers below costal margin 14cm
1.
2.
3.
4.
5.
6.

Malaria
Leishmaniasis
CML--- chronic myeloid leukemia
CLL----chronic lymphocytic leukemia
Portal hypertension---- liver cirrhosis is the commonest.
Myelofibrosis

Causes of mild splenomegally :

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1. 1.Infection --- HAV ,glandular fever , EBV , CMV, infective endocarditis,

malaria ,leishmaniasis
2. Inflammation---- SLE , Rhemtaoid arthritis , sarcoidosis
3. Ischemia----- portal vein thrombosis
4. Tumour---- lymphoma ,leukemia
5. Tuberculosis --- military
6. Portal hypertension
How can you differentiate splenomegally from enlarged kidney on the left side of
abdomen?
For splenomegally ,
1.
2.
3.
4.
5.

Direction of enlargement ----- toward the right iliac fossa toward the midline
Continuity of the dullness on percussion note
Movement with deep breathing as it is intraperitoneal
Splenic notch over the medial site
The examiner cant insert the fingers below the left costal margin

For the kidney,

1. Ballottement is the pathognomic sign
2. Area of resonance over the mass

PERCUSSION:

Helps to identify the amount & distribution of gas and to identify

possible masses that are solid or fluid filled.
Percussing the abdomen produces different sounds based on the
underlying tissues.
Sounds help you detect excessive gas and solid or fluid-filled masses
Also help you determine the size and position of solid organs such as
the liver and spleen.
By Percussion , you are looking for areas of tympany and dullness
Expect to hear tympany in most of the abdomen
Expect dullness over the solid abdominal organs such as the liver and
spleen
Can be used to assess size of liver and spleen
On the right, it is the liver dullness; on the left, dullness of the
spleen, kidney ,colonic mass.
The liver span is estimated by percussion.
Remember that it is easier to hear the change from resonance to dullness so proceed
with percussion from areas of resonance to areas of dullness.

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1.upper border from 2nd
intercostal space through
mid clavicular line, start
percussing on the chest
moving down towards the
abdomen about to 1 cm at
a time. Note where the
percussion notes change
from resonate to dull which
is the beginning of the liver
border((upper)).

2.lower border from right

iliac fossa though
midclavicular line and
ascend toward costal margin
till the dullness note start
which is the beginning of the
liver border(( lower)).
Liver span is normally 6 to
12 cm in the midclavicular line which is the distance between upper and lower borders.

For spleen,

When a spleen enlarges, it

expands downward and medially
toward the right iliac fossa and
pushed the umbilicus to be flat .
Fullness in the left hypochondrial
may be the first clue of
spleenomegally. Spleen
enlargement replaces the
tympany of the stomach with the
dullness of a solid organ

Percussion cannot confirm

splenic enlargement, but it can
raise your suspicion.

There are two techniques to

percuss splenic enlargement.

Percuss the left lower anterior

chest wall between lung
resonance (6 IC) above & the
costal margin (an area termed
Traubes space)

As you percuss laterally, note the extent of the tympany; if tympany is prominent
laterally, splenomegaly is unlikely.

Can also check for a splenic percussion sign

Percuss the lowest interspace in the left anterior axillary line; the
area is usually tympanitic
Then ask the patient to take a deep breath and percuss again
When the spleen is normal, the space usually remains tympanitic

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ASCITES

Shifting Dullness

Percuss
centrally
from
the
epigstrium to umbilicus then to
each flank
Locate point of change on side
Ask patient to roll towards you
Wait.for a minute for fluid to move
Percuss again ?area of dullness moved

Fluid Thrill

to other side

Use patients right hand in midline

Flick one side and feel the other side

This is done if the patient has huge abdomen which is tense

and difficult to palpate and there is no area of central
resonance for comparison and for fluid to move from side to
another.

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What are the causes of ascitis?

As apart of generalised cause (( with bilateral pitting pedal odema ))
1.
2.
3.
4.
5.
6.

Portal hypertesionliver cirrhosis

Chronic renal failure
Nephrotic syndrome
Hypothyrodism
Congestive heart failure
Protein losing enteropathy

As a part of local abdomenal disease,

1.
2.
3.
4.
5.
6.

Tuberculosis
GIT tumours--- stomach ,colon , pancrease
Metastases to the peritoneum
Connective tissues diseases
Budd chiari syndrome
Acute pancreatitis

AUSCULTATION:

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Provides important information about bowel motility:

decreased motility suggests peritonitis; increased motility
suggests obstruction
Need to listen before percussion or palpation since these
maneuvers may alter the frequency of bowel sounds
Can also appreciate BRUITS over the aorta or other
arteries, suggesting narrowing of the arteries from
atherosclerosis
Bruits are high pitched sounds due to obstruction to flow
due to narrowing (stenosis) of arteries
Listen midline (bruit in aorta)
Right / left upper quadrant (renal artery bruits)

Listen with diaphragm of stethoscope

Normal sounds occurs every 5-10 seconds & consist of
clicks and gurgles
Need to listen for 2 minutes to declare no bowel sounds;
since bowel sounds are widely transmitted, need only to
listen in one spot
Occasionally hear borborygmi - long, prolonged gurgles of
hyperperistalsis - the familiar stomach growling

SUMMARY PONTS:
1. BOWEL SOUNDS
a. ABSENT
b. LOUD
2. VENOUS HUMS
a. B/W XIPHISTERNUM AND UMBILICUS
3. Renal Bruit
4. Hepatic Bruit
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Succussion Splash
Puddle Sign

Cover the patient up

Turn to the examiner

I would like to complete my examination

by examining the external genitalia,
performing a digital rectal examination and
dipstick the urine.

You can ellicit succussion splash in

normals following ingestion of aerated
drink. Whenever there is air and fluid inside a bowel you can ellicit
this sign.
NOTE:
Special manevures may also be performed, to elicit signs of specific diseases. These
include

Gallbladder: Murphy's sign

It is performed by asking the patient to breathe out and then gently placing the hand below
the costal margin on the right side at the mid-clavicular line (the approximate location of
the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during
inspiration, the abdominal contents are pushed downward as the diaphragm moves down. If the
patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in
contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered
positive. In the elderly the sensitivity is markedly lower; a negative Murphy's sign in an
elderly person is not useful for ruling out cholecystitis if other tests and the clinical
history suggest the diagnosis

Courvoisier's law:

States that in the presence of an enlarged gallbladder which is non tender and
accompanied with mild jaundice, the cause is unlikely to be gallstones. Usually, the term
is used to describe the physical examination finding of the right-upper quadrant of the
abdomen. This sign implicated possible malignancy of the gall bladder or pancreas and
the swelling is unlikely due to gallstones(( because gallstones are formed over an
extended period of time, resulting in a shrunken, fibrotic gall bladder which does not
distend easily)). This shrunken gallbladder is less likely to be palpable on exam. In
contrast, the gallbladder is more often enlarged (and more easily palpated) in pathologies
that cause obstruction of the biliary tree over a shorter period of time such as pancreatic
malignancy leading to passive distention from back pressure. Note that a
palpable tender gallbladder may be seen in acute acalculous cholecystitis, which
commonly follows trauma or ischemia and causes acute inflammation of the gallbladder in
the absence of gallstones.
The exceptions to the law are stones that dislodge and acutely jam the duct distally to the hepatic/cystic duct junction:

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1.

Gallstone falling and blocking the Ampulla of Vater

2.

Gallstone falling and blocking the cystic/hepatic duct junction

.The psoas sign: is a medical sign that indicates irritation to the iliopsoas group of hip flexors in
the abdomen, and consequently indicates that the inflamed appendix is retrocaecal in orientation (as
the iliopsoas muscle is retroperitoneal). It is elicited by performing the psoas test by passively
extending the thigh of a patient lying on his side with knees extended, or asking the patient to
actively flex his thigh at the hip. If abdominal pain results, it is a "positive psoas sign". In particular,
the right iliopsoas muscle lies under the appendix when the patient is supine, so a positive psoas
sign on the right may suggest appendicitis. A positive psoas sign may also be present in a patient
with a psoas abscess. It may also be positive with other sources of retroperitoneal irritation, e.g. as
caused by hemorrhage of an iliac vessel.

.Blumberg's sign is a sign that is elicited during physical examination in medicine. It is indicative of peritonitis.
The abdominal wall is compressed slowly and then rapidly released. A positive sign is indicated by presence of
pain upon removal of pressure on the abdominal wall. It is very similar to rebound tenderness

Appendicitis or peritonitis:

Psoas sign - pain when tensing the psoas muscle

Obturator sign - pain when tensing the obturator muscle

Rovsing's sign - pain in the right iliac fossa on palpation of the left side of
the abdomen

Carnett's sign - pain when tensing the abdominal wall muscles

Patafio's sign - pain when the patient is asked to cough whilst tensing the
psoas muscle

Cough test - pain when the patient is asked to cough

Suspected Pyelonephritis: Murphy's punch sign

Hepatomegaly: Liver scratch test

Ascites: bulging flanks, fluid wave test, shifting dullness

IF THE PATIENT HAS A HUGE ASCITIS , WHAT IS THE COMMONEST CAUSE AND
WHAT OTHER SIGNS YOU HAVE TO LOOK FOR?

Liver cirrhosis with portal HTN is the commonest cause.

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The signs that you have to look for are the stigmata of chronic liver
disease.
They are:
Jaundice , spider neavi , Gyanecomastia in male & Breast atrophy in
female , flapping tremors ,palmer erythema , muscle wasting ,
kilonychia ,leuchonychia , ecchymosis , pedal odema.
Those are mandatory to look for in any case of abdominal
examination.

THANKS

MAGDI AWAD SASI

HOPPING , IT WILL HELP AND ALLAH ACCEPT MY TRIAL TO HELP

OTHERS

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