Part 2: SEQUENCE OF Abdominal

ASSESSMENT
 The physical Examination
The elective physical Examination
• The examining room and table should be comfortable

• And drapes should be used

• Inform the patient

• Lay the subject supine with arms by the side

• Expose the abdomen, including the groin parts

• Only from xiphoid process (xiphisternum) to pubic symphysis

 SEQUENCE OF ASSESSMENT

• Inspection
• Auscultation
• Percussion
• Palpation
• Examination of the body orifices
 INSPECTION

• Stand at his right side and perform general

inspection of the abdomen
Noting in particular:
Symmetry of its shape and the presence
of markings and scars

►Lower yourself until the anterior abdomen wall

is at eye level and note:
the shape (contour)
and movement of the abdomen
►Ask the patient to breath normally while you are
doing so
 INSPECTION

• ►►Stand up again and direct your attention to the subject’s groin bilaterally

• Ask him to cough and observe the cough impulse along the inguinal canal
 INSPECTION

Normal Findings
■ Contour (shape)
Flat
Rounded
Scaphoid
Protuberant
(distended)
 INSPECTION
• Normal Findings
• Movement
• ►Rises and falls rythmically with inspiration
and expiration respectivelly

• ►Pulsation of abdominal aorta may be seen

in the epigastrium of a slender person

• Cough impulse
• ► No cough impulse should be seen along
the inguinal canal
 INSPECTION

• Abnormal findings
• Skin
• Pigmentation (change)
lesion (dermatologic)
Striae
Turgor
Scars
Superficial vessels
Shape (asymmetrical ► enlargement of
intraabdominal organ, Gross tumor)
Movement ( minimal or absent ► peritonitis)
Abdominal Striae
 Superficial vessels
Illustration
 AUSCULTATION
The purpose of auscultation of the abdomen is to
listening for bowels sounds produced by peristaltic
activities and vascular sounds (bruits)

• ►►Bowel sounds may be

* Active bowel sounds 5-30/min
* Hypoactive bowel sounds 4/min or less

* Hyperactive bowel sounds 30 or more /min

 AUSCULTATION
• Vascular sounds (bruits)
* The abdominal aorta sounds at the
epigastrium
• The renal arteries sounds at the
hypochondrium bilaterally
• (or costovertebral angle at the back
bilaterally)
* The iliac arteries sounds in the center of
each lower quadrant
* The femoral arteries sounds just below the
mild-point of the inguinal ligament bilaterally
AUSCULTATION FOR BRUITS
 Percussion
• Purpose:
• To delineate
►The borders of the liver, the enlarge spleen,
presence of other masses
► Presence of fluid (ascites)
► Abdominal distention (gas-filled bowels)
 Percussion

• ►Five (5) sound notes may be evoked,

depending on the site and underlying pathology
• 1) the sound noted is flat when the site is over
soft tissue or fluid
• 2) the sound noted is dull when the site is over
solid organ beneath a layer of lung
• 3) the sound noted is resonant when the site is
over air-filled lung tissue
• 4) the sound noted is hyper resonant when the
site is over air-filled pleural cavity
• 5) the sound noted is tympanic when the site is
over air-filled bowel
PERCUSSION OF SPLEEN
 Exercise (percussion)
• 1) Percuss your thigh and listen to the evoked sound
note. (The underlying tissue is fat, muscle and bone).

• 2) Percuss your right chest just under the clavicle and

listen to the evoked sound note. ( The underlying tissue
is air-filled lung).

• 3) Percuss your right chest at the right mid-clavicle line

above the costal margin and listen to the evoke sound
note. (the underlying tissue is lung over liver
• 4) Percuss the left upper quadrant of your abdomen
below the costal margin and listen to the evoke sound
note. (the underlying stomach may contain a large gas
bulbble.
 On the back
Pounding on the Costovertebral angle
► Should not cause pain.
If pain ►►often it is associated with renal
disease
 Percussion

• ► If dullness in flanks►► check for

shifting dullness test
 Percussion
• ► If indicated check for fluid wave
test
 PALPATION
• It is important that you warm your hand before
your palpate the abdomen of your patient

• Half flexing the patient’s knees will help to relax the

abdominal musculature and make the palpation
easier

• There are 4 phases to palpation of the abdomen:

• 1) light palpation
• 2) deep palpation
• 3) bimanual palpation, and
• 4) palpation of groin
 PALPATION

• 1) Light palpation:
• The purpose of light palpation is to check:
•
• ►) abdominal muscle tone
• ►) cutaneous hepersensibility
• ►) tenderness
• ►) Presence of superficial masses

• When it is performed well it can help gain

the confidence of the patient and prepared
him for deep and, bimanual palpation
 PALPATION
► Deep palpation
The purpose of deep palpation is to feel for organs
in the deep of the abdominal cavity

The procedure is similar to light palpation but firm

steady pressure is used

However you should avoid digging your fingers into

the abdominal wall

Some practitioner use a two-hand approach to apply

firm pressure when palpating for the cecum or sigmoid
colon in the right and left iliac region respectively
 Exercice (light palpation)
• 1) Ask the patient if any part of the abdomen is tender

• Start palpation as far from that area as possible

• 2) Place the palm of your hand flat on the abdomen

• Palpate gently and apply pressure by flexing the finger in

unison at the metacarpal phalangeal joints. Check for muscle
tone, tenderness and rebound tenderness as you proceed
• 3) Move your hand through all regions and palpate the entire
abdomen in systematic manner
Light and Deep Palpation

Illustration
 Bimanual Palpation

• ► Should be applied to organs that move with respiration

• Example liver and gallbladder:
• Exercise:
• Lay the patient supine and stand on his right.
• Slide your left hand behind the patient’s lowermost ribs on the right.
• Place your other hand flat on the anterior abdominal wall, with fingerpoints upwards,
lateral to the rectus muscle, and just below the costal margin.
• Simultaneously push forwards with the posterior hand and press inward and upward with
anterior hand.
• Ask the patient to take deep breath through the mouth.
• Near the peak of the inspiration allow the finger hand to rise the abdominal wall.
• You may feel the edge of liver or slide under your hand. A normal liver is not tender.
 PALPATION

palpation for liver

 Liver Palpation
Other alternative
Palpation for Spleen
Rebound tenderness
ON BACK
IF ABDOMINAL PAIN
Tachypneic

Learning Forward

* Murphy’s sign

* Rovsing’s sign

* Iliopsaos test

* Obturator’s sign
 RULES IF IN ABDOMINAL PAIN

• Do not administer pain medication:

Antispasmodics
Anticholinergics
Smooth muscle relaxants

Before a medical diagnosis, because mask pain

 CONTREINDICATION FOR ABDOMINAL
ASSESSMENT

• Never palpate a if suspected:

• Appendicitis ??
• Dissecting abdominal aortic aneurysm
• Polycystic kidneys

• Do not palpate or percuss transplanted

organs
 Things to Remember
• Consider groin / rectal examination in males

• Consider pelvic/ rectal examination in females

THANKS