]Abdominal Exam

Preliminaries The examiner introduces themselves and/or provides appropriate transition to the exam The purpose of the exam is explained The comfort of the patient is addressed The patient is invited to ask questions now or at any time in the future The examiner washes his or her hands before touching the patient Positioning Exam is conducted from the right side of the patient Patient supine Arms resting at the side Patient asked to relax abdominal muscles If muscles remain tense, patient may be asked to rest feet on table with hips and knees flexed

Inspection

Skin Scars Tattoos Striae Abnormal venous patterns Aortic pulsation Contour noted (scaphoid, flat, or protuberant)

Auscultation Diaphragm of stethoscope used Skin depressed to approximately 1 cm Auscultation for bowel sounds Described as present if heard Described as absent at one minute, if not heard after one minute, with auscultation distributed across four quadrants Auscultation for vascular sounds (bruits) Aortic (midline between umbilicus and xiphoid Renal (two inches superior to and two inches lateral to umbilicus) Common iliac (midway between umbilicus and midpoint of inguinal ligament) Percussion (technique) DIP joint of third finger (pleximeter) pressed firmly on the abdomen Remainder of hand not touching the abdomen Striking hand should move only at the wrist, with only little more than force of gravity Middle finger of striking hand (plexor) should knock the pleximeter firmly, with a strong note Palpation (light) Entire palm of one hand is used Abdominal wall depressed approximately 1 cm in systematic pattern over abdomen Any areas of pain or tenderness are reserved for evaluation at the end of the exam Light palpation assesses Muscle tone Cutaneous hypersensitivity (suggests peritoneal irritation)

Presence of superficial (intramural) masses Intramural mass is more prominent if patient raises their head Intra-abdominal mass is less prominent if patient raises their head

Palpation (deep) Either one- or two-handed technique is acceptable In two-handed palpation, the top hand applies pressure to the bottom hand, which palpates Palpate deeply with finger pads (do not dig in with finger tips) Push as deeply as patient will allow without significant discomfort Palpating hand is held steady while patient inhales Palpating hand is lifted and moved while the patient breathes out Rebound tenderness is sought by rapidly lifting hand from abdomen after deep palpation Costovertebral angle (CVA) tenderness is sought by palpating the posterior CVA this may be done in supine or seated position Examination of Liver Percussion Midclavicular line is noted Second intercostal space is noted (using Angle of Louis) Percussion begins over the second intercostal space and proceeds downward Upper margin is noted by first dull percussion note Lower margin is noted by first tympanitic note Palpation Deep technique used to palpate inferior edge Starting point is in right iliac fossa, and proceeds upward Palpating hand is held steady while patient inhales Palpating hand is lifted and moved while the patient breathes out Examination of Spleen Percussion (at Castells Spot) Castells Spot identified Left anterior axillary line identified Left lower costal margin identified Percussion at Castells Spot while patient inhales and exhales deeply Dull tone indicates possible splenomegaly Palpation (low sensitivity) Deep technique used Starting point is RLQ, proceeding to LUQ Palpating hand is held steady while patient inhales Palpating hand is lifted and moved while the patient breathes out Repeating palpation with patient in right lateral decubitus improves sensitivity of palpation for detection of splenomegaly Examination of Kidney Kidney trapped between one hand over the CVA and another under the anterolateral costal margin Right kidney may be felt to slip between hands during exhalation Examination of Aorta Flat palm placed over the epigastrium to locate pulse Hands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpated Lateral width of pulsation is determined by space between index fingers

Examination for Shifting Dullness Percussion from anterior abdomen laterally to flank until dullness noted Patient rolled slightly toward the examined side; movement of the dull point medially is described as shifting dullness and suggests ascites