Abdominal examination

The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.

The exam includes several parts:

• Setting and preparation
• Inspection
• Auscultation
• Percussion
• Palpation

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Setting and preparation

Position - patient should be supine and the bed or examination table should be flat. The patient's hands should remain at his/her sides with his/her head resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend her knees so that the soles of her feet rest on the table will also relax the abdomen.

Lighting - adjusted so that it is ideal.

Draping - patient should be exposed from the pubic symphysis below to the costal margin above - in women to just below the breasts. Some surgeons would describe an abdominal examination being from nipples to knees.

Physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment. Separate systematic reviews by the Cochrane Collaboration^[1] and the Rational Clinical Examination^[2] refute this claim.

Inspection

The patient should be examined for: -

• masses
• scars
• lesions
• signs of trauma
• bulging flanks - best done from the foot of the bed
• jaundice/scleral icterus
• abdominal distension

Stigmata of liver disease

• spider angiomata
• temporal wasting
• fetor hepaticus

Hands

• clubbing
• thenar wasting
• Dupuytren's contracture
• palmar erythema

Estrogen related

• spider nevi

Estrogen-related in males

• testicular atrophy
• gynecomastia

Associated with portal hypertension

• hematochezia (blood in stool)
• hematemesis - gastric bleed, esophageal varices
• caput medusae (rare) - venous distension
• ascites

Auscultation

Auscultation is sometimes done before percussion and palpation, unlike in other examinations. It may be performed first because vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus the bowel sounds. Additionally, it is the least likely to be painful/invasive; if the person has peritonitis and you check for rebound tenderness and then want to auscultate you may no longer have a cooperative patient.

Pre-warm the diaphragm of the stethoscope by rubbing it on the front of your shirt before beginning auscultation. One should auscultate in all four quadrants, but there is no true compartmentalization so sounds produced in one area can generally be heard throughout the abdomen. To conclude that bowel sounds are absent one has to listen for 5 minutes. Growling sounds may be heard with obstruction. Absence of sounds may be caused by peritonitis.

Percussion

• all 9 areas
• percuss the liver from the right iliac region to right hypochondriac
• percuss for the spleen from the right iliac region to the left hypochondriac and the left iliac to the left hypochondriac.

Examination of the spleen

• Castell's sign or alternatively Traube's space

Palpation

• All 9 areas - light then deep.
• In light palpation, note any palpable mass.
• In deep palpation, detail examination of the mass, found in light palpation, and Liver & Spleen
• Palpate the painful point at the end.

Other

• Digital rectal exam - Abdominal examination is not complete without a digital rectal exam.
• Pelvic examination only if clinically indicated.

Special maneuvers

Suspected cholecystitis

• Murphy's sign

Suspected appendicitis or peritonitis

• Obturator sign
• psoas sign
• rebound tenderness
• Rovsing's sign
• Cough Test

Hepatomegaly

• scratch test

Examination for ascites

• bulging flanks
• fluid wave test
• shifting dullness

References

1. ^ Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M (2007). "Analgesia in patients with acute abdominal pain". Cochrane database of systematic reviews (Online) (3): CD005660. doi:10.1002/14651858.CD005660.pub2. PMID 17636812.
2. ^ Ranji SR, Goldman LE, Simel DL, Shojania KG (2006). "Do opiates affect the clinical evaluation of patients with acute abdominal pain?". JAMA 296 (14): 1764-74. doi:10.1001/jama.296.14.1764. PMID 17032990.