Abdominal examination

 

Attention

  • Make person as comfortable as possible, respect privacy
    • Warm room, empty bladder
    • Gentle approach — start as far from painful area as you can
  • Palpate/percuss for a reason, to answer question such as — is there guarding in right iliac fossa, mass in left upper quadrant, enlarged bladder
    • Do not poke or prod abdomen — palpate and percuss gently
    • Do not palpate/percuss longer than needed to answer question/s
  • Watch person’s face during examination to see if they have pain, keep them relaxed
  • Mentally divide abdomen into 4 areas (quadrants), know what organs lie in each — Figure 9.20
    • Start examination well away from painful area, be sure to examine all quadrants, leave painful area/s to last
  • Do examination in following order
    • Look — for abnormalities, asymmetry
    • Auscultate — listen for bowel sounds
    • Percuss — check for tenderness, size of organs, masses, air and/or fluid in abdomen (ascites)
    • Palpate — feel for masses, enlarged organs, tenderness, guarding, rigidity
  • If you find anything abnormal or worrying — medical consult

Figure 9.20  

What you need

  • Warm hands with short nails
  • Stethoscope
  • Waterproof/permanent marker
  • Disposable tape measure
  • Pain relief

What you do

  • Lie person on back, arms by sides, pillow under head
  • If person in distress/pain — give pain relief now

Look

  • Does person look malnourished (very thin)
  • Jaundice — check if whites of eyes look yellow
  • Does abdomen move with respiration
  • Signs of injury, bruising
  • Prominent capillaries (spider naevi) or veins visible
  • Abdomen swollen/distended
    • Where is fat/fluid lying — see Assessing ascites
    • Lumps, bulges, rashes, scars
    • Umbilicus — in midline, bulging out
  • Pregnancy signs — linea nigra (brown discolouration from umbilicus to pubis), striae (stretch marks)
  • Peristalsis (bowel moving under skin)
  • Pulsing of aorta or femoral arteries

Do

Listen — with stethoscope (auscultation)

Don’t spend a lot of time listening to abdomen. Interpretation of abdominal sounds is very individual, doesn't add much to clinical picture. Not a good discriminator, few or lots may be normal, can be serious abdominal pathology with normal sounds

  • Listen for 30–60 seconds in area of umbilicus
    • If no bowel sounds heard — record as absent
    • If bowel sounds present — are they plentiful, if plentiful, loud and tinkling — may be obstruction
    • Lots of gurgling may come before diarrhoea, or may be normal

Percuss

  • Use same technique as percussing chest
  • Percuss very lightly at first, start as far from tender/painful area/s as possible, cover all quadrants
  • Listen for 
    • Hollow, tympany (drum-like sound) — normal over air filled organs (eg stomach, bowel)
    • Dullness (dull sound) — normal over enlarged liver or spleen, full bladder, uterus. These organs have no overlying bowel
  • Use tape to measure
    • Distance liver or spleen extend below ribcage in mid-clavicular line
    • Height of bladder or uterus above pubic bone

To percuss liver

  • Start in mid-clavicular line over lower right lung (just below nipple) then work down. Sound will be hollow over lung
  • Use pen to mark where sound becomes dull as you pass over top edge of liver
  • Start in right lower quadrant, percuss upward until hollow sound of bowel changes to dullness at bottom edge of liver
  • Confirm bottom edge by light palpation, usually within 2cm of rib cage. Mark this point
  • Measure between 2 marks

To percuss spleen

Can only percuss if enlarged. Need to distinguish from enlarged kidney or stomach tumour

  • Do not percuss spleen if left upper quadrant pain/tenderness — might cause damaged/diseased spleen to rupture
  • In mid-clavicular line, percuss upward from level of umbilicus
    • Enlarged spleen sounds dull on percussion
    • If covered by bowel — usually sounds hollow
  • Confirm by light palpation. Mark this point
  • In mid-clavicular line, measure from ribcage to mark

To percuss bladder

  • Do after person has emptied bladder
  • Start at pubic bone, percuss up toward umbilicus
  • Enlarged bladder sounds dull
  • Enlarged uterus and large ovarian masses also sound dull — may be mistaken for bladder

Palpate

  • Always start palpation far away from where complains of pain, examine painful area last
  • 2 types of palpation — far more information gained from light palpation than deep palpation
    • Light palpation — use flat hand and feel with index finger (leading) edge. Press lightly in smooth, gentle movements. Will show up pain, tenderness, tense muscles, some masses, organs lying close to skin (eg liver, spleen, uterus, bladder)
    • Deep palpation — use more pressure and press deeper (up to 5–7cm if person obese). Can use both hands, one on top of the other. This will show up deep pain, masses, shape/size of deeper structures (eg kidneys, aorta)

To palpate liver

  • Use light palpation to check area you marked during percussion
  • Start from right lower quadrant, working upward 2–3cm at a time
  • At each site, ask person to take a deep breath
    • If liver or gall bladder enlarged — will feel bottom edge being pushed down by diaphragm
  • Normal liver often palpable 1–2cm below ribcage in mid-clavicular line
  • Gall bladder tender if infected (cholecystitis)

To palpate spleen

In adults you only feel spleen if enlarged. Otherwise protected by lower left rib cage. Occasionally feel edge of normal spleen in children. Can be difficult to palpate and easily missed even when very enlarged

Spleen can be enlarged in

  • Trauma (subcapsular haemorrhage)
  • Leukaemia
  • Myelofibrosis
  • Certain infections — malaria, glandular fever (EBV)
  • Cirrhosis (portal hypertension) occasionally complicated by enlarged spleen

If left upper quadrant tenderness — be very gentle palpating for spleen as injured/enlarged spleen can rupture easily

  • Lie person on right side, facing you
  • Sit down with right hand lying horizontally on abdomen at umbilicus
  • Feel with leading edge of index finger. Press gently toward left lower rib cage as person breathes in
  • Repeat 4–5 times, each time bringing hand a little closer to rib cage
  • Measure in mid-clavicular line from ribcage

To palpate kidneys

  • Kidneys and adrenal glands are deep, usually difficult to palpate
  • Enlarged kidneys usually polycystic
  • Kidney and adrenal tumours occasionally palpable, especially in children
  • Lower pole of right kidney may be felt if person very thin
  • Right kidney
    • Stand on person's right side, facing their head
    • At level of umbilicus, put left hand under person’s back half way to midline, put right hand on right abdomen one hand's breadth from midline
    • Ask person to take a deep breath and hold for a moment
    • With flats of fingers, press up with left hand and down with right to ‘capture’ and bounce (ballot) kidney between them — Figure 9.21
    • As person breathes out, partially release pressure of right hand, may feel kidney slide back into original position

Figure 9.21  
  • Left kidney

    • Move to person’s left side facing head, repeat procedure with hands in opposite positions

To palpate bladder

Pregnant uterus or large ovarian cyst/tumour can be mistaken for bladder

  • Have person try to empty bladder
  • Stand on person's right side. Starting above umbilicus use fingers of left hand to lightly palpate into lower abdomen
  • Will only feel bladder if distended

Assessing ascites

Attention

  • Ascites is excess fluid between abdominal organs and abdominal wall. Always abnormal
  • If abdomen swollen — may be ascites

What you need

  • Helper
  • Waterproof/permanent marker
  • Tape measure

What you do

Percussion wave test

  • Person lies on back
  • Ask helper to press down firmly in midline with side of hand — Figure 9.22
  • Face person's head and put your hands either side of abdomen
  • Tap side of abdomen with right hand. Check for ‘ripple’ or ‘wave’ of fluid across abdomen that you can see and feel with left hand — Figure 9.22

Figure 9.22  

Shifting dullness test

  • Person lies on back, stand to side of person
    • Percuss from umbilicus to side away from you
    • Normal air filled bowel — Figure 9.23 will sound hollow (tympany)
    • If fluid (ascites), hollow sound will change to dullness. Mark this point (transition point 1) — Figure 9.24
  • Roll person onto side facing you, wait a minute for ascites to move down with gravity
    • Percuss from upper side of abdomen toward umbilicus
    • Mark point where hollow sound changes to dullness (transition point 2) — Figure 9.25
  • If ascites, transition point marks will be at least 3cm apart — Figure 9.25

Figure 9.23  

Figure 9.24  

Figure 9.25