Please go through these slides for the clinical practical for MBBS BDS BPT BSc MLT BPharm etc

1. Clinical Examination of per
abdomen
Chiranjeevi Kumar
Department of Physiology
AIIMS Bhopal

2. Abdominal Exam
•Inspection
•Auscultation
•Percussion
•Palpate
percussion includes percussion of
liver span, light and deep
palpation, palpation of liver edge,
spleen tip, kidneys, and aorta.
Order of exam is critical. Auscultate BEFORE
palpating!

3. History taking - summary
• Abdominal pain
• Dysphagia
• Nausea and vomiting
• Anorexia and unexpected weight loss
• Abdominal gas
• Abdominal distension
• Diarrhea
• Constipation
• Gastrointestinal bleeding
• Jaundice

4. Enhancing the Exam
 Empty bladder
 Patient comfort (pillows and draping)
 Arms at side or crossed over chest
 Legs semi-flexed to relax the abdomen
 Ask him to relax and breath quietly
 Ask the patient to point to any painful areas; examine last
 Warm hands and stethoscope
 Ticklish or nervous patients: slow movements, distraction, use their hands
4

5. General principles of exam
• If muscles remain tense, patient may be asked to rest feet
on table with hips and knees flexed

6. General principles of exam
• If the patient is ticklish or frightened
• Initially use the patients hand under yours as you palpate
• When patient calms then use your hands to palpate.
• Watch the patient’s face for discomfort.

7. Think Anatomically

8. Think Anatomically
• When looking, listening, feeling and percussing.
• imagine what organs live in the area that you are examining.

9. Right Upper Quadrant (RUQ)
• liver, gallbladder, duodenum, right kidney and
hepatic flexure of colon

10. Right Lower Quadrant (RLQ)
• Cecum, appendix (in case of female, right ovary &
tube)

11. Left Upper Quadrant (LUQ)
• Stomach, spleen, left kidney, pancreas (tail),
splenic flexure of colon

12. Left Lower Quadrant (LLQ)
• Sigmoid colon (in case of female, left ovary & tube)

13. Epigastric Area
• Stomach, pancreas (head and body), aorta

14. Surface Anatomy
14

15. Regions

16. Inspection

17. ABDOMEN: Inspection
There should be
adequate
exposure of the
abdomen for
proper
inspection. The
patient should be
exposed from the
inferior chest to
the anterior iliac
spines bilaterally.

19. Abdominal Physical Exam
Inspection
Contour
Flat
Scaphoid
Distended
Symmetry
Movement
Peristaltic
Respirations
Aortic pulsation
Skin
Scars – cicatrix
Striae
Discoloration
Venous patterns
Edema
19

20. Symmetrical in shape
Scaphoid or flat in young patients of
normal weight
Slightly full but not distended in older age
group due to poor muscle tone or in subjects
who are mildly overweight

21. Appreciation of abdominal contours
• Standing at the foot of the table and looking up towards the
patient's head.
• Lower yourself until the anterior abdominal wall and ask the
patient to breathe normally while you are doing so.

22. Appearance of the abdomen
• Global abdominal enlargement is usually caused by Flatus,
fluid, fetus, full bladder, food, feaces or fat.

23. abdomen_ascites
Abdomen obese
abdomen_umbo_hernia1 abdomen_umbo_hernia2

24. Appearance of the abdomen
• Localized enlargement probably distend GB space
occupying lesion, hepatomegaly….

25. An aortic aneurysm
• Palpable mass
• Patient feeling of pulsation
• On rare occasions, a lump can be visible.

26. An aortic aneurysm
• 1 in 10 men over 65 may have some enlargement of the
abdominal aorta.
• About 1 in 100 will have a large aneurysm requiring
surgery.

27. Appearance of the abdomen
(Skin)
• Abnormal venous patterns
• Abnormal discoloration
• Umbilicus is sunken

28. Striae
• Stretch marks are a light silver hue.
• Pregnancy and obese individuals
• Cushing’s syndrome (more purple or pink).

29. PINK-PURPLE STRIAE OF CUSHING’S
SYNDROME

30. Cullen’s sign
• Ecchymosis periumbilically. (intraperitoneal
hemorrhage, ruptured ectopic pregnancy, hemorrhagic
pancreatitis..)

31. Grey-Turner’s sign
• Ecchymosis of flanks. (retroperitoneal hemorrhage such as
hemorrhagic pancreatitis)

32. Upward flow direction indicates IVC obstruction

34. Outward flow pattern from umbilicus in all directions ? Portal HTN

35. SCAR

36. DILATED VEIN OF HEPATIC
CIRRHOSIS

37. RASHES

38. UMBILICAL HERNIA IN NEWBORN

39. Contour of the abdomen
PROTUBERANT
SCAPHOID
(newborn with diaphragmatic
hernia)

40. Visible Pulsations
• More conspicuous in the
thin than in the fat
• Greater in the old than in
the young.
• Increased in thyrotoxicosis,
hypertension, or aortic
regurgitation)
• In those with an aortic
aneurysm and tortuous
aorta
• In those who have a mass
joining the aorta to the
anterior abdominal wall.

41. Visible gastric Peristalsis
• Gastric peristalsis is
commonly seen in
neonates with
congenital hypertrophic
pyloric stenosis
• Intestinal peristalsis in
partial and chronic
intestinal obstruction
• Colonic obstruction is
usually not manifest as
visible peristalsis
Visible intestinal Peristalsis
Visible Peristalsis

42. Auscultation
Abdominal examination
Bowel sounds
Vascular sounds (bruits)
Friction Rubs

43. Auscultation for bowel sounds
• It is performed before percussion or
palpation

44. Auscultation for bowel sounds
• Compared to the cardiac and pulmonary exams,
auscultation of the abdomen has a relatively minor role.

45. Auscultation
Auscultation can be
done with the
diaphragm or the bell;
most examiners use
the diaphragm. You
should listen for at
least 10-15 seconds
and note the pitch
and frequency of
bowel sounds. If you
do not hear any bowel
sounds, you should
listen for a full two
minutes before you
can state that the
patient does not have
any bowel sounds.
Bowel sounds should
occur from every
other second to every
12 seconds.
Note: During the
abdominal exam auscultation is done
before palpation

47. Three things about bowel sound
Bowel sounds cannot be said to be absent unless they
are not heard after listening for 3-5 minutes.
• Are bowel sounds present?
• If present, are they frequent or sparse (i.e.quantity)?
• What is the nature of the sounds (i.e.quality)?

48. Bruits
• Bruits confined to systole do not necessarily indicate disease.

49. 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)

50. Venous Hum (rare)
• Epigastric/umbilical area.
• Soft humming noises in systolic/diastolic component.
• Indicates collateral between portal and venous systems as
in hepatic cirrhosis.

51. Rubs –Rubs-Rubs
• Liver
• Spleen
• Cardiac
• Pulmonary

52. Friction rubs (rare)
• Right and left upper
quandrants
• Grating sound with
respiratory movement
• Indicates inflammation
of the capsule of the
liver or spleen (infection
or infarction).

53. Abdominal Physical Exam
Auscultation
4 quadrants
15-20 seconds
Bowel sounds
Frequency
Pitch
Vascular Sounds
Renal
Iliac
Femoral
53

54. Abdominal Physical Exam
Percussion
Notes Elicited
Tympanic – Hollow viscous
Predominant due to gas in GI tract
Hyperresonant – air (lungs)
Dull
Organs, fluid and feces
Distension of abdomen
Fluid vs. Air
Outline Organs
Liver, spleen, and gastric bubble
54

56. There are two basic sounds with
Percussion
• Tympanitic (drum-like) sounds produced by
percussing over air filled structures.

57. There are two basic sounds with
Percussion
• Dull sounds that occur when a solid structure (e.g.
liver) or fluid (e.g. ascites) lies beneath the region being
examined.

59. Percussion
Percussion: the left and right abdomen should be percussed
above and below the umbilicus. Most examiners will percuss 8
or more areas.

60. Percussion: Liver span
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.
Upper border: In the midclavicular line start
percussing in the chest moving down towards the
abdomen about ½ to 1 cm at a time. Note where the
percussion notes change from resonate to dull.
Lower border: In the midclavicular
line begin percussion below the
unbillicus and proceed upward until
dullness is encounter.
The distance between the
two areas where dullness is
first encountered is the liver
span.
Liver span is normally 6 to 12 cm in
the midclavicular line.

61. Liver Span: Scratch Test
Start in the same areas
above and below the
liver as you would with
percussion. Instead of
percussing lightly,
scratch moving your
finger back and forth
while listening over the
liver. Since sound is
conducted better in
solids than in air, when
the louder sounds are
heard you are over the
liver. Mark the superior
and inferior boarders of
the liver span in the
midclavicular line

63. Examination of Liver (Percussion)
• Midclavicular line is noted
• Second intercostal space is noted

65. To determine the size of the liver
• Measure the liver span
by percussing hepatic
dullness from above
(lung) and below
(bowel).
• A normal liver span is 6
to 12 cm in the
midclavicular line.

68. Physical examination
Percussion
• Liver span midclavicular line: 6-12 cm
midsternal line: 4-8 cm
• Splenic dullness
– normal: in the midaxillary line
– pathological:dullness in the ant. axillary line
during inspiration
• Liver or/and splenic dullness absent: perforation.
• Shifting Dullness
• Horse shoe shaped dullness
• Fluid thrills

69. Shifting Dullness

71. Abdominal Palpation
Technique
• Light
• Deep
• Liver edge
• Spleen tip
• Kidneys
• Aorta
• Masses

72. Abdominal palpation
• To palpate four quadrants superficially from LLQ
counterclockwise

73. Light Palpation

74. Light Palpation
• Mostly looking for areas of tenderness
• Tenderness is a physical exam finding a reflex occurs
(muscle splinting, wide eyes, moaning, teeth gritting).

75. Abdominal muscle spasm
• Voluntary guarding
Tensing abdominal
muscles due to patient
anxiety, ticklishness, or
to prevent palpation to
a painful area
Involuntary guarding
• Muscular spasm or
rigidity due to
peritoneal inflammation
• May be localized (early
appendicitis )or diffuse
(perforated bowel)

76. Board-like rigidity
• If abdominal wall is palpated as obviously tense, even as
rigid as a board, board-like rigidity is so called.
• Is caused by the spasm of abdominal muscle due to
peritoneal irritation.

77. Deep Palpation

78. Abdominal Palpation
Palpate lightly in all 4 quadrants. Press
down around 1 cm. Remember to look
at the patient’s face during palpation
to see if any tenderness is elicited

79. Palpation: Deeply, all 4 quadrants
One should use two hands. Press
down around 4 cm

80. Palpation: Liver
Stand on the pt’s right side. Place your left hand behind the
patient’s R side under the 11th and 12th rib area. Press upward
with the L hand.
Place your R hand on the pt’s
abdomen well below where you
percussed the liver edge

81. Palpation of Liver: Alternative Method
It is acceptable during palpation of the liver to
use both hands to palpate abdomen. You use
the fingers of one hand to palpate and the other
hand is used to apply pressure to the dorsum of
the other hand. Thus the hand you are using to
palpate does not need to be used to apply
pressure.

82. Hepatomegaly
• More than 1cm below the costal margin
• An exception is a congenitally large right lobe of the liver
• Severe, chronic emphysema

83. Palpation: Spleen
Palpation: Spleen
(correctly - position,
breaths, palpating
deepest full
inspiration, 1 hand
under L side, 1
feeling)
Palpation: Spleen (if
not palpable, R lateral
decubitus)

84. Right
lateral
decubitus

86. Palpation of Kidneys
Right kidney (take a deep
breath, capture kidney, exhale,
slowly release kidney
Left kidney (take a deep breath,
capture kidney, exhale, slowly
release kidney)

87. Fluid wave or Thrills

90. 137: Palpation: For abdominal
aorta
Palpation: For
abdominal aorta (to
feel both the left and
right walls of the
aorta)
In correct order:
Inspection,
auscultation,
percussion and
palpation
Abdominal
Examination was
done at 0.

91. Abdominal Physical Exam
Practice- 20 Minutes
• Inspection
– Contour
– Skin
– Movement
• Auscultation
– Bowel sounds
– Vascular sounds
• Percussion
– Abdomen for masses or fluid
– Liver span
– Spleen
– Gastric bubble
– Shifting Dullness
– Horse should shaped dullness
– Fluid thrills
• Palpate
– General palpation
– Liver
– Gallbladder
– Spleen
– R and L kidneys
– Abdominal aorta
– Inguinal lymph nodes
• Special:
– Murphy’s sign
– McBurney’s point
– Rovsing’s sign
– Psoas sign
– Obturator sign
– Rebound tenderness
– CVA tenderness
91

92. Murphy’s Sign (acute cholecystitis)
• Examiner’s hand is at middle inferior border of liver.
• Patient is asked to take deep inspiration.
• If positive patient will experience pain and will stop
short of full inspiration
Hepatitis, subdiaphragmatic abscess
Cholecystitis

93. McBurney’s Point (Appendicitis)
• Localized tenderness
Just below midpoint of
line between right
anterior iliac crest and
umbilicus.
• Heel strike, riding over
bumps in road while
driving, coughing, will
produce pain.

94. Rovsing’s Sign
• Patient will experience
right lower quadrant
pain (in region of
McBurney’s Point)
when left lower
quadrant is palpated.

95. Non-Classical Appendicitis
• Iliopsoas Sign
• Obturator Sign

96. Iliopsoas Sign
Patient can lay on side and extend leg at the hip or
have patient lay on back and try to flex hip against
the resistance of examiner’s hand on thigh. If patient
has an inflamed retrocecal appendix, this will
produce pain.

97. Obturator Sign
• Internally rotate right leg at the hip with the knee at
90 degrees of flexion. Will produce pain if inflamed
appendix is in pelvis.

98. Rebound Tenderness
(For peritoneal irritation)
• Warn the patient what you
are about to do.
• Press deeply on the
abdomen with your hand.
• After a moment, quickly
release pressure.
• If it hurts more when you
release, the patient has
rebound tenderness.

99. Costo - vertebral Tenderness
(Often with renal disease)
• Use the heel of your
closed fist to strike
the patient firmly over
the costovertebral
angles.
• Compare the left and
right sides.