UAB School of Medicine

Physical Exam Practice

Guide


Contents
The Abdominal Exam ............................................................................................................................................... 3
LEARNING OBJECTIVES for this GUIDE ............................................................................................................................ 3
Introduction ............................................................................................................................................................................ 4
Instruments......................................................................................................................................................................................... 4
General Examination Guidelines .............................................................................................................................................. 5
Important Background info on ANATOMY of the ABDOMEN ..................................................................................... 6
ANATOMIC CORRELATIONS for ABDOMINAL PAIN....................................................................................................... 8
INSPECTION ............................................................................................................................................................................. 9
General Inspection ........................................................................................................................................................................... 9
Inspection of the Abdomen ......................................................................................................................................................... 9
AUSCULTATION .................................................................................................................................................................... 11
Auscultation (bowel sounds) ...................................................................................................................................................11
Auscultation (vascular sounds) ...............................................................................................................................................11
PERCUSSION .......................................................................................................................................................................... 13
PALPATION ............................................................................................................................................................................ 16
Palpation (general)........................................................................................................................................................................16
Palpation (liver) ..............................................................................................................................................................................17
Palpation (spleen)..........................................................................................................................................................................19
SPECIAL TESTS ..................................................................................................................................................................... 21
Tests for Ascites (abdominal fluid) .......................................................................................................................................21
Test for Cholecystitis (Gall Bladder inflammation) ....................................................................................................... 23
Tests for Suspected Peritonitis ................................................................................................................................................24
Testing for Kidney .........................................................................................................................................................................26
Palpation of the Aorta ..................................................................................................................................................................27
Testing for an abdominal wall mass or ventral hernia ................................................................................................27
Pelvic and/or Rectal Exams ......................................................................................................................................................28
Closing the Encounter ........................................................................................................................................................ 28



The Abdominal Exam

LEARNING OBJECTIVES for this GUIDE

Competency Goal Skill Objectives

Body touch and • Wash/sanitize hands before and after encounter
handling • Touch patient in a gentle manner accommodating to cultural variation
in appropriateness of touch
Appropriate draping • Demonstrate proper draping to maintain patient modesty
Interpersonal • Appropriately explain the examination to the patient while performing it
Patient Positioning • Describe proper positioning of the patient for the abdominal exam
• Describe techniques to relax the abdomen to facilitate an optimal
exam
• Properly and safely manipulate a standard exam table to change
patient positions and facilitate a proper exam.
Abdominal exam • Describe the proper sequence of the components of the abdominal
exam and the rationale for this sequence
INSPECTION
• Describe and identify key surface landmarks of the abdomen
• Describe standard approaches to localizing findings in the abdomen
(quadrants vs. nine sections) and the corresponding visceral organ
located in each area
• Describe potential findings notable on inspection
AUSCULTATION
• Identify the characteristics of normal bowel sounds
• Describe variations in bowel sounds and their implications
• Demonstrate listening for bowel sounds
• Demonstrate proper technique to listen for vascular bruits in the
locations where they are likely to be heard
PERCUSSION
• Demonstrate proper technique for percussion
• Percuss the abdomen and identify areas of dullness and tympany
• Demonstrate proper technique for measurement of the liver span by
percussion
• Demonstrate proper technique for percussion of Traube’s space to
assess for splenic enlargement
• Assess for tenderness to percussion over the Costovertebral angles
PALPATION
• Demonstrate proper technique for palpation, including light and deep
general palpation as well as palpation of the liver and spleen
• Examine areas of pain last
• Assess for tenderness to palpation over the Costovertebral angles
OTHER
• Demonstrate tests for peritoneal irritation (rebound, psoas and
obturator maneuvers, Murphy’s sign, Rovsing’s sign)

• Demonstrate proper techniques to detect ascites (Shifting dullness,
fluid wave)

Note: Examination of the kidneys is not often clinically useful, so this is

not a required part of the abdominal exam for ICM

Introduction

Overview: As with other organ system exams, the abdominal exam is broken down into the 4 basic
parts of a physical exam: inspection, palpation, percussion, auscultation – often shortened to “IPPA.”
However, the abdominal exam is unique in that it places the step of auscultation prior to percussion
and palpation. Performing percussion and/or palpation before auscultating could artificially stimulate
bowel sounds that you would not have heard otherwise, and thus alter your findings.

Note: While pelvic and/or rectal examinations should be considered components of a proper evaluation
of a patient complaining of abdominal pain – they will not be performed in this context. Learners can
verbalize, “Next I would perform pelvic and rectal exams,” but they will not actually do so with SPs
during this training. (ICM students will have training sessions during the MS2 year on these more
sensitive exams)

Instruments
Before beginning, make sure that all of the following instruments are on-hand:
1. Stethoscope
2. Drape/sheet
Introduction

PEP-list Items Description/References

q Knock on the door Start the encounter by respecting your patient’s privacy.

q Confirm the patient’s Determine how the patient prefers to be addressed. “Do you prefer
identity that I call you Mary or Ms. Brown?”

q Introduce yourself to the

State your first and last name. “My name is [First] [Last].”
patient

q Explain your role in the

“I am a first year medical student.”
health care team

Explain your plan and obtain consent for the examination.

q Negotiate an agenda for
the encounter “I’d like to examine your abdomen today. Is that okay with you? Do
you have any questions before we start?”

PEP-list Items Description/References

q Wash or sanitize your

Foam sanitizer or soap and water are acceptable.
hands

q Confirm that the patient’s “This exam is more comfortable – and more accurate – if you have
bladder is empty an empty bladder. Have you used the restroom recently?”

General Examination Guidelines

PEP-list Items Description/References
While practicing the exam, verbalize each step to the patient before
you perform it. Be sure to avoid medical jargon, and when
appropriate, ask for permission to proceed. Talking through the steps
allows the patient to understand your intentions and may help you
q Explain each step of the better learn the steps of the exam. Asking permission to proceed is
exam before you perform particularly important for more sensitive or intrusive parts of the
it, and ask permission to exam, or when the patient is having discomfort.
proceed when appropriate
“Ms. Smith, next I need to touch your neck to feel your thyroid gland.
It might feel a bit uncomfortable, but it should not hurt. If it does hurt,
or if you want me to stop, please let me know. Is it ok for me to do
this exam?”

Positioning yourself on the patient’s right side is a long-standing

q Stand on the patient’s right
medical tradition. It creates standardization among the exams and
side, if possible
the profession.

q Perform your exam on Clothing, such as a gown, can generate sound that masks heart
bare skin (you should not sounds. For the most accurate/correct results, place the stethescope
palpate/percuss or directly on the skin.
auscultate through the It is also poor technique to “snake” the stethescope under the gown
gown) or clothes.

Use proper draping technique to permit a thorough exam while

q Draping protecting the patient’s modesty. For details, see below under “Bikini
Drape section just before starting the “Cardiac exam” section

Not only are cold hands or a cold stethoscope uncomfortable for the
q Warm hands and
patient, they may cause the patient to tense the muscles of their
stethoscope
abdomen, making the exam more difficult to perform.

q Follow the recommended

Note: The abdominal exam is unique in that it places the step of
sequence for the
auscultation prior to percussion and palpation
Abdominal Exam (IAPP)

Recommended sequence: Inspection, Auscultation, Percussion,
Palpation (Special Tests-if needed)

Ask the patient to touch the area on their abdomen where they are
experiencing pain/discomfort.
q Inquire about areas of
tenderness so you may Introducing touch on areas that are not painful can help a patient
examine those areas last relax and get acquainted to your touch. Examining the area where
they are having pain first can alter the rest of the exam and should
be avoided.

Important Background info on ANATOMY of the ABDOMEN

q Review Surface Anatomy
of the Abdomen and
corresponding underlying
anatomy
Take a few minutes to familiarize yourself with the figures below. Fig.
1A shows important surface landmarks that will be referenced
throughout this guide and any abdominal exam resources. Fig 1B.
illustrates healthy and normal positioning of the abdominal organs you
will be assessing.

A B

Fig. 1: Images depicting (A) Important landmarks for abdominal exam and (B) the underlying abdominal anatomy.

Key Anatomic Landmarks to know and be able to identify include:

Anterior:
• Xiphoid process to symphysis pubis
• Inguinal ligaments
• Anterior superior iliac spines
Costal margins179.65

Posterior:
• 11th and 12th ribs
• Costovertebral angle

Other: mid-axillary and mid-clavicular lines

q Review the schema for Because the abdomen contains many different organs and
localizing problems in the structures, dividing it into quadrants or sections can be helpful in
abdomen (quadrants vs. localizing symptoms and their potential underlying causes. Two such
sections) schemes are depicted below. Both are used in practice.

Dividing the Abdomen into Four Quadrants Dividing the Abdomen into Nine Sections



ANATOMIC CORRELATIONS for ABDOMINAL PAIN

§ Visceral pain: when hollow organs (stomach, colon)
forcefully contract or become distended
o Usually gnawing, cramping, or aching and is often
difficult to localize
o Familiarize yourself with different o Solid organs (liver, spleen) can also generate this type
patterns of abdominal pain of pain when they swell against their capsules (ex.
Hepatitis).
Visceral pain
§ Parietal pain: when there is inflammation from hollow or
Parietal Pain solid organs that affect the parietal peritoneum
Referred Pain o Usually severe and is easily localized (appendicitis)
§ Referred pain: originates at different sites but shares
innervation from the same spinal level (gallbladder pain in
the shoulder)

Location of Kidney or Ureteral Pain

Anatomic correlations for Visceral Pain


INSPECTION
General Inspection
PEP-list Steps Description

q General appearance Skin color, temperature, body habitus (overweight, obese), etc.

Your awareness of contextual cues helps establish rapport with the

q Signs of discomfort or
anxiety
patient. It also informs you of how to interact with the patient. (i.e.
avoid ‘small-talk’ with a patient that is writhing in pain) and may give
your clues about the underlying problem. (For example, patients with
peritonitis often lie very still as any movement aggravates the pain,
whereas patients with “colic” may be in constant motion trying to find
a comfortable position. Recognizing these clues can help you as you
try to understand the cause of their illness.

q Level of consciousness This will be more relevant for the clerkships, but it is important to
and orientation assess patient competence.

Inspection of the Abdomen

PEP-list Items Description/References

If there is not room for the patients arms on the table, the patient may
cross their arms on their chest, but they should never place them
overhead (this engages the muscles of the abdomen and can
q Position patient supine, interfere with your exam of the abdomen).
completely flat: arms at Additional positioning option: In some patients who are having
side difficulty relaxing their abdomen, having them keep their knees bent
during the exam can help relax the muscles of the abdomen and help
with tickleishness. Note: If the abdomen is sufficiently relaxed with
legs straight, there is no need to ask them to bend them.

Before you lift the gown, make sure the patient has a sheet draped
across their lap.
q Drape patient You can expose just the abdomen by lifting the gown to the bottom of
appropriately to protect the sternum and lowering the sheet to the top of the pubis. Having
modesty but also to both a sheet and a gown helps protect the patient’s modesty.
adequately expose the
abdomen for a proper To better expose the lower part of the abdomen, you can fold the
exam sheet over the patient’s undergarments and then slide everything
down.


q Inspect abdomen from

Inspecting from both positions helps visualize the entire abdomen,
beside the patient & from
especially with respect to contour.
the foot of the exam table

Surface Markings: Look for striae, vascular changes (like dilated

veins), lesions, or rashes. If you notice scars, ask about their origin.
o - Umbilicus – note location, and any
o inflammation or bulges
Contour: Is the abdomen flat, rounded, protuberant, or scaphoid
q Observe contour, (markedly concave or hollowed)? Do you see any bulging in the
symmetry, movement, and flanks (ascites) or any localized bulges (distended bladder, pregnant
surface markings uterus, or hernias)?
Symmetry: Do you see any visible masses or enlarged organs
(especially the spleen and liver)?
Movement: Look for pulsations (most likely from the abdominal
aorta) or visible peristalsis.
See page Bates pgs. 464-465 for examples of abnormalities.



AUSCULTATION

q Auscultate for bowel sounds

q Auscultate for vascular bruits
q Overview
See descriptions below

Auscultation (bowel sounds)

PEP-list Items Description/References
Using the diaphragm of
your stethoscope, listen
for the presence or
absence of bowel
sounds. Continue
listening until you hear
bowel sounds or for
one full minute.
Listening in one
quadrant (see Figure
q Listen until bowel sounds 2) of the abdomen
are heard or for a full should be sufficient
minute unless you are
evaluating a patient Fig. 2: Four quadrants of the
with abdominal abdomen
complaints, in which
case you may need to listen in all 4 quadrants.
Normal sounds consist of clicks, gurgles, and pings. Report sounds
as increased, decreased, or normal. Normal frequency is 5-30 per
minute.
Bowel sounds may be altered in diarrhea, intestinal obstruction,
paralytic ileus and peritonitis. See Bates Table 11-10 Sounds in
the Abdomen for more details.

Auscultation (vascular sounds)

PEP-list Items Description/References

Auscultate with the
diaphragm over the
abdominal aorta to
listen for bruits*.
Auscultate over the
branches of the aorta
as depicted in the
q Listen for bruits:
diagram (you can
Abdominal aorta and
draw an “X” through
branches
the umbilicus to
approximate the
Fig. 3: Locations for auscultation of
locations of the vascular sounds
arteries)
*Bruits are caused by partial obstruction of the vessel and can be
compared to the sound of water pushing through a kinked water
hose. Epigastric bruits confined to systole are normal.

Push down firmly with your stethoscope 1 inch above the umbilicus
q Listen: Renal arteries and 1 inch lateral to the umbilicus to evaluate for renal artery bruits.
Make sure to compare side to side.

Move to the lower quadrants to auscultate the iliac arteries. Make

q Listen: Iliac arteries
sure to compare side to side.

Move to the inguinal regions to auscultate the femoral arteries. Make

q Listen: Femoral arteries
sure to compare side to side.


PERCUSSION

q General Percussion
q Percussion of the Liver and Spleen
See descriptions below
q Overview Note: Doing percussion before palpation can help you to identify any
abnormal areas of dullness and evaluate for possible enlargement of
the liver and spleen and approximate their locations before beginning
palpation.


PEP-list Items Description/References

Place the distal joint of your non-dominant middle finger on the

patient’s abdomen, doing so firmly enough to conduct through the
fatty layers of the abdomen. Hyperextend the finger so that the distal
q Perform General interphalangeal (DIP) joint is flat on the skin. Avoid surface contact
Percussion of the by any other part of the hand, because this dampens out vibrations.
abdomen to assess the Use the middle finger of your dominant hand to strike quickly (not
amount and distribution of forcefully) twice on the distal joint of the hand on the abdomen. i.e.
gas in all four quadrants “tap-tap.”
and identify areas of
dullness Repeat this percussion in all four quadrants - and the midline - of
the abdomen, outlining areas of dullness and tympany. In a healthy
abdomen, you will mostly hear tympany. Dullness suggests the
presence of anything that is not air (e.g. organs, masses, fluid, or
simply feces in the colon).

Percussion of the liver and spleen helps you to identify the location of
the organs and whether there may be any enlargement or
q Percuss the Liver and displacement of the organs prior to palpating for them
Spleen

The techniques for each are described below.

Percussing the Liver


q Percuss the liver in the
right midclavicular line,
assess margins and liver
span
A B
Fig. 4: (A) Pattern and location for liver percussion. (B) Normal Liver span.
PEP-list Items
q Percuss for dullness in
Traube’s space (to
identify splenic
enlargement)
Begin percussing in the right midclavicular line at the level of the
umbilicus. This area should be tympanic. Percuss upward until
tympany changes to dullness (Fig. 4A). This is the lower margin of
the patient’s liver. Continue percussing upwards until dullness
changes to tympany. This is the upper margin of the liver.
Measure in centimeters the distance between the two points – the
vertical span of the liver. Normal liver span ranges are 6-12 cm in the
right midclavicular line and 4-8 cm in the midsternal line (Fig. 4B).
NOTES: It is appropriate to ask a woman to move her breast if it
interferes with the examination. If she is unable to lift her own breast,
you may ask her permission to shift it yourself. Always use the back
of your hand in this situation.
Make sure to percuss between the ribs as percussing on a rib will
give you a dull sound.
Percussing the Spleen
Description/References
The spleen sits beneath the
ribs. Percuss in the area known
as Traube’s space (fig. 6).
Dullness in this area can be a
sign of splenic enlargement.
To assess for an enlarged
spleen, percuss the left lower
anterior chest wall roughly from
the border of cardiac dullness
at the 6th rib down to the

anterior axillary line and down to the costal margin (the area known as
Traube’s space).. Dullness to percussion in this area may indicate an
enlarged spleen (Fig. 7).

Note: Bates also describes a Splenic percussion test (variation on

above). See the text for details, but for the purposes of ICM, splenic
percussion is not a required maneuver.


PALPATION

q General Palpation
q Palpation of the Liver and Spleen
q Overview
See descriptions below

Palpation (general)

PEP-list Items Description/References

If you palpate the tender area/s first, the patient may begin guarding,
q Palpate any areas of
which may make the rest of the palpation more difficult and may alter
tenderness last
your exam findings.

q Observe patient’s face It is important to observe the patient’s face rather than solely relying on
for signs of discomfort the patient to report pain.

If the patient is not experiencing abdominal pain, you may choose to

palpate only 4 areas – once in each quadrant. If the patient is
experiencing abdominal pain, you should palpate in all 9 named
segments of the abdomen (Fig. 8A). Follow a systematic pattern,
palpating any tender areas last.
Keeping your hand and forearm on a horizontal plane, with fingers
q Palpate lightly 4 - 9 together and flat on the abdominal wall, palpate the abdomen with a
areas for tenderness, light, gentle, dipping motion. As you move your hand to different
guarding, or rigidity quadrants, raise it just off the skin. Identify any superficial organs or
(use one hand) masses and any area of tenderness or increased resistance to your
hand. (Fig. 8B).
Note: Gentle palpation is
especially helpful for
A B
eliciting abdominal
tenderness, muscular
resistance, and some
superficial organs and
masses. It also serves to
reassure and relax the
patient.

Fig. 8: (A) Nine named regions of the abdomen. (B) One-handed light palpation.

Light palpation gives the patient an opportunity to get accustomed to

your touch (cold hands, ticklish sensation, etc.). It helps the patient relax
the abdominal muscles so that you can more easily and effectively

q Palpate deeply 4 - 9
areas (use both hands)
Note: Deep palpation is
especially helpful for
delineating abdominal
masses. Deep palpation
may not be possible in an
area of acute pain.
perform deep palpation. Involuntary guarding that does not decrease
with light palpation can be a sign of peritoneal inflammation.
If a patient is very ticklish, you can try placing the patient’s hand under
your hand while palpating and ask the patient to breathe through their
mouth with their jaw dropped open.
Use both hands to palpate deeply in the same pattern that you used to
palpate lightly.
Place your dominant hand on the abdomen and use the non-dominant
hand on top of the dominant hand to apply pressure in a dipping, rolling
motion.
Remember to flex your fingers only at the metacarpophalangeal joints
(the bottom knuckle) to avoid digging into the patient’s abdomen (Fig.
9).
Warn the patient that this part of the
exam can be uncomfortable but it
should not cause distinct pain—if it
does, you should stop and notify
your supervisor.
Feel for any masses or organ
Fig. 9: Deep palpation with two hands
enlargement. If you do feel a mass,
take note of the size, shape, position, tenderness, mobility, and/or
pulsations.
Palpation (liver)

PEP-list Items Description/References

Place your left hand behind the patient, parallel to and supporting the
right 11th and 12th ribs and adjacent soft tissues below. By pressing
your left hand upward, the patient’s liver may be felt more easily by
your other hand.
Place your right hand on the patient’s right abdomen lateral to the
rectus muscle, with your fingertips well below the lower border of
liver dullness (the liver edge may be missed by starting palpation too
high in the abdomen). Some examiners like to point their fingers up
toward the patient’s head, whereas others prefer a somewhat more
oblique position, as shown in Fig. 11A. In either case, press gently in
and up.
Ask the patient to take a deep breath. Try to feel the liver edge as it
comes down to meet your fingertips. (Your palpating hand should be
stationary as they inhale. Inhaling expands the chest and lungs
which forces the diaphragm down, and in turn the liver as well).

q Palpate the liver edge Place the fingers of your right hand just below the point where you
(bimanual or hooking percussed the lower margin of the liver (inferior to the ribs) in the
technique) midclavicular line (Fig. 11A).
Note the location where you feel the liver edge (ex. 3cm below the
right costal margin in the mid-clavicular line) and whether the liver is
soft or hard, whether you feel any nodules, and whether it is tender to
the touch. The normal liver edge is soft, sharp and regular with a
smooth surface. The normal liver may be slightly tender.

PEP-list Items Description/References
An alternate technique for palpating the liver edge is known as the
“Hooking Technique.” This is particularly helpful for obese patients.
Position your body at the level of the patient’s shoulders. Use your
fingers on both hands and “hook” them underneath the costal margin,
below the point where you percussed the lower margin of the liver.
Press your fingers in and up toward the patient’s head and then ask
the patient to take a deep breath (Fig. 11B).

A B

Fig. 11: (A) Palpation of the liver with two hands. (B) Hooking technique for liver
palpation.

Palpation (spleen)

PEP-list Items Description/References

q Palpate the spleen
o with patient supine
o with patient lying on left
side
Note: palpating with patient
on the left side is not always
required, but can be
especially helpful if
splenomegaly is suspected
from the history or other parts
of the PE (ex. percussion
suggests dullness in Traube’s
space)
Note: Palpation for the Kidneys is described in Bates, but is not an expected
maneuver for ICM
Remain on the right side of the patient. Place your left hand on the
patients left flank to support and press forward the lower left rib cage
and adjacent soft tissue. With your right hand below the left costal
margin, press inward and upward toward the spleen. (Begin palpation
low enough so that you are below a possibly enlarged spleen).
Ask the patient to take a deep breath into their abdomen. Try to feel
for the splenic edge as it comes down to meet your fingertips (Fig.
12).
Note any tenderness, assess the splenic contour and measure the
distance between the spleen’s lowest point and the left costal margin.
The edge or tip of the spleen is palpable in a small percentage of
healthy adults (~5%). In most cases, if you feel the spleen it is
suggestive of splenic enlargement.
Repeat the
palpation with the
patient lying on
their right side with
their legs
somewhat flexed
at the hips and
knees. In this
position, gravity
may bring the
spleen forward
and to the right
into a palpable
Fig. 12: Location and palpation of the spleen
location.

SPECIAL TESTS

Special Tests are not done routinely, but in selected instances where
appropriate based on the patient’s presenting symptoms.
q Tests for Ascites (excess abdominal fluid)
o Shifting Dullness
o Fluid Wave
q Test for Cholecystitis (Gall Bladder inflammation)—Murphy’s sign
q Tests for Peritonitis
q Overview o Rebound tenderness
o Rovsing’s Sign)
o Psoas Maneuver
o Obturator sign
q Costovertebral angle tenderness (kidney inflammation)
q Palpation of the Aorta
q Testing for an abdominal wall mass or ventral hernia
See descriptions below

Tests for Ascites (abdominal fluid)

When fluid accumulates in the peritoneal cavity, it is called ascites. A protuberant abdomen with
bulging flanks suggests possible ascites. The tests below should be performed if ascites is
suspected.

Because ascitic fluid characteristically sinks with gravity, whereas

gas filled loops of bowel rise, abdominal ascites will be first
q Inspection of the flanks
manifested as bulging of the flanks if the patient is lying supine.
for bulging
Inspection of these areas should be performed in anyone suspected
of having ascites. See Diagram below in next section.

Percussion of the abdomen in a patient with ascites who is lying flat

on their back should reveal dullness at the flanks and as the ascites
q Shifting Dullness
worsens, the dullness will progress centrally towards the umbilicus
(as depicted in the diagram below).


Assessing for shifting dullness is the preferred test to confirm

the presence of ascites. (The test confirms that the area of
dullness moves with position changes, suggesting it is free fluid and
not a solid structure). Shifting dullness can detect as little as 1 liter
of fluid in the abdomen.
Procedure for assessing for Shifting Dullness: Have the patient lie
on their back. Start percussing at the midline of the abdomen and
move laterally, continuing to percuss. Note the location when the
sound changes from tympany to dullness. You may choose to mark
this point with a pen.
After percussing the border of tympany and dullness with the patient
supine, ask the patient to turn onto one side. Percuss and mark the
borders again. In a person without ascites, the border between
tympany and dullness usually stay relatively constant. In ascites,
dullness shifts to the more dependent side, whereas tympany
shifts to the top (Fig. S2A).

This test is more specific for ascites, but not very sensitive (large
volumes of fluid must be present for this test to be positive, so it is
not as useful as shifting dullness unless there is a large amount of
ascites).
Use the patient’s or another health professional’s hand to press
firmly along the midline of the patient’s abdomen using the edges of
the hands. This will help to keep fat and other structures in the
q Fluid Wave
abdomen from transmitting a wave when you tap on the abdomen..
Place one hand on each of the patient’s flanks. Use one hand to tap
sharply on one side of the patient’s abdomen (Fig. S2C). If fluid has
accumulated in the abdomen, this will create a wave of fluid that
travels across the belly and hits the hand on the opposite side. If
you see this wave, or feel it on your second hand, this is a sign
suggestive of ascites.

A B C

Fig. S2: Fluid movement with position, as in Ascites. Fluid distribution when (A) supine and (B) When lying on left side. (C)
Hand positions and simulated fluid movement for fluid wave test.

Test for Cholecystitis (Gall Bladder inflammation)

To check for
cholecystitis, assess
for Murphy's sign
(Fig. S3).
Press firmly over the
q Murphy’s Sign gallbladder (where
the edge of the
rectus abdominal Fig. S2: Murphy’s sign: Palpation of gallbladder
muscles meets the (green)
costal margin). Ask
the patient to inhale deeply. If the patient catches her breath
(cessation of inspiration) due to pain at the point of palpation, this is

a positive Murphy’s sign. Be sure to watch the patient’s face to
monitor for pain as you perform this test.

Tests for Suspected Peritonitis

Locate the anterior superior iliac spine. Usually called the ASIS,
these are the protruding bones on the front of the pelvis that are
referred to non-clinically as the “hips.”
Find the right ASIS and imagine an imaginary line between it and the
umbilicus. McBurney's point is located two-thirds the way down this
line toward the ASIS (Fig. S4).
Palpate deeply over McBurney’s point. If the patient feels pain at this
point upon deep palpation, it may indicate appendicitis.
q Localize pain and
tenderness to McBurney’s
Point (can suggest
appendicitis)

Fig. S4: McBurney’s Point with anatomical context


Signs of peritoneal irritation or inflammation are particularly important
to note because they can suggest a condition that may require
urgent or emergent surgery. These signs include: Rebound
tenderness, involuntary guarding and muscular rigidity (of the
abdomen). Voluntary guarding (the patient’s abdomen relaxes when
distracted) can be seen with many other conditions and is less
q Rebound Tenderness and suggestion of peritoneal inflammation.
other signs of peritoneal
irritation
To test for rebound tenderness, press down on the abdomen slowly
and deeply. Then quickly release your pressure.
Ask the patient whether it was more painful when you pressed down,
or when you released. Rebound tenderness is present if more pain
was felt upon release. This is a positive sign for peritonitis.

Rovsing’s Sign: Classically described as rebound tenderness in LLQ

with appendicitis. This sign is present if pain was felt in any areas
q Rovsing’s Sign other than where you tested for rebound tenderness. Ex. If you
perform the test on the left side, but the patient experiences rebound
tenderness at McBurney's point, this a positive sign for appendicitis.

Another test for

appendicitis is the
obturator sign. With the
patient in a supine
position, raise the
patient's right leg and flex
the knee.
Maneuver the leg to
q Obturator Sign
create internal rotation at
the hip (the knee will
move toward the midline
of the body and foot will Fig. S5: Obturator Sign: Internal rotation at
move away from the the right hip
midline). See figure 3.2.
Pain may support the diagnosis of appendicitis (due to irritation of the
obturator muscle by the inflamed appendix).

q Psoas Sign
Testing for Kidney (costovertebral angle) tenderness
q Costovertebral angle
(CVA) tenderness
The psoas sign is also a test for appendicitis.
Ask the patient to roll onto her left side and extend right leg
backwards (Fig. S6). Place
your hand above the right
knee and ask the patient to
push against your hand.
Alternately, you may ask the
patient to raise her right leg
against resistance from your
Fig. S6: Psoas Sign: Flexion at the right hip
hand while lying flat on her
back.
Pain with this maneuver may indicate appendicitis (due to irritation of
the psoas muscle by the inflamed appendix).
Place the palm of one
hand over the posterior
costovertebral angle
(Fig. S1). Warn the
patient that they will feel
you knocking firmly on
both sides of their back.
Quickly strike your flat
hand with your other fist.
Make sure to watch the Fig. S1: Costovertebral Angle Tenderness
patient's face for signs of
discomfort. Repeat on the other side.
Tenderness at the CVA may be a sign of pyelonephritis
(inflammation of the kidney).
Alternatively, you can press in the same area with your fingertips
first to assess for tenderness.

Palpation of the Aorta
This test should be performed with caution in anyone suspected of or known to have an aortic
aneurysm, especially if they are having abdominal pain.

Palpate deeply in the upper abdomen, slightly to the 
 left of midline. Observe the abdominal aorta’s
prominence and its strength of pulsations.

Assess the width of the aorta by pressing deeply with one hand on either side of the aorta. This is
generally easier to assess in older patients.

Testing for an abdominal wall mass or ventral hernia
Ventral hernias are hernias in the abdominal wall exclusive of groin
hernias and are typically located in the midline above the umbilicus
Occasionally, abdominal masses or other abnormalities can be
found in the abdominal wall rather than within the abdominal cavity.
q Ventral Hernia
q Abdominal Wall Mass
To identify either condition, ask the patient to raise his/her head
and shoulders off the table and inspect and palpate the area in
question for a hernia or mass. A mass in the abdominal wall
remains palpable with this maneuver, whereas an abdominal mass
is obscured by muscular contraction.



Pelvic and/or Rectal Exams

Both of these exams are important components of a complete

q Pelvic and Rectal exams
abdominal exam, especially for patients experiencing abdominal
pain. They will not be performed in this specific teaching context but
will be covered later in sessions during the MS2 year.
You may state, “At this point, I would normally perform a pelvic and
rectal exam.” (for a female patient)

Closing the Encounter

PEP-list Items Description/References

At this point in your education, you will discuss any “findings” with
your supervising physician or instructor before speaking with the
q Summarize information patient about them.
gathered in physical exam However, you can explain to the patient what you have done, and
what the next steps are. “This completes the abdominal exam. I will
go speak with the medical team to decide our next steps.”

q Inquire if patient has “Do you have any questions or concerns regarding the exam or
questions or concerns how you are feeling?”

q State appreciation to “Thank you for working with me today. Our team is going to do
patient everything we can to get you feeling better.”

q Shake hands (if appropriate)

q Wash/sanitize your hands Foam sanitizer or soap and water are both acceptable options.

GUIDE AUTHORS:
Erin Dorman, MS
Mark Pepin, MS
Stanford Massie, MD
Finalized March 14, 2018

Note: All pictures and tables are taken from Bates 11th Edition online unless otherwise specified.
None of the pictures should be used for any other purpose without permission of the publisher of the
Bates textbook.