Examination of the Abdomen Lab

George J. Scott, D.P.M., D.O.

Equipment Needed

A Stethoscope

General Considerations

The patient should have an empty bladder.

The patient should be lying supine on the exam table with the abdomen
sufficiently exposed for inspection. The genitals should be appropriately draped to
preserve patient modesty and maintain their dignity.
The examination room must be quiet to perform adequate auscultation and
percussion.
By convention the abdominal examination is conducted with the examiner
positioned on the patients right side.
By convention the abdominal examination is conducted in the following
sequence: 1) Inspection

2) Auscultation
3) Percussion
4) Palpation

Watch the patient's face for signs of discomfort during the

examination.
Use the appropriate terminology to locate your findings:
o Right Upper Quadrant (RUQ)
o Right Lower Quadrant (RLQ)
o Left Upper Quadrant (LUQ)
o Left Lower Quadrant (LLQ)
o Midline:
Epigastric
Periumbilical
Suprapubic
Disorders in the chest can often manifest with abdominal symptoms. It is always
wise to examine the chest when evaluating an abdominal complaint.
Consider the inguinal/rectal examination in males. Consider the pelvic/rectal
examination in females.

1) Inspection
1. Look for scars, striae, hernias, vascular changes, lesions, or rashes. [1]
2. Look for movement associated with peristalsis or pulsations.
3. Note the abdominal contour. Is it flat, scaphoid, or protuberant?
1 G.J.Scott, D.O.

2) Auscultation
1. Place the diaphragm of your stethoscope lightly on the
abdomen. [2]
2. Listen for bowel sounds in all 4 quadrants. Are they
normal, increased, decreased, or absent?
3. Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch3.html
4. Listen for bruits over the aorta, renal arteries, iliac arteries,
and femoral arteries.
5. Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch4.html

3) Percussion
1. Percuss in all four quadrants using proper technique.
2. Categorize what you hear as tympanitic or dull. Tympany is
normally present over most of the abdomen in the supine position.
Unusual dullness may be a clue to an underlying abdominal mass.
3. Percuss liver, spleen and kidneys (CVA Tenderness)
4. Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch5.html

Liver Span
1. Percuss downward from the chest in the right midclavicular line
and midsternal line until you detect the top edge of liver dullness.
2. Percuss upward from the abdomen in the same lines until you
detect the bottom edge of liver dullness.
3. Measure the liver span between these two points. This
measurement should be 6-12 cm in the midclavicular line, and 4
8 cm in the midsternal line in a normal adult.

Splenic Dullness
1. Percuss the lowest costal interspace in the left anterior
axillary line. This area is normally tympanitic.
2. Ask the patient to take a deep breath and percuss this area
again. Dullness in this area is a sign of splenic enlargement.

2 G.J.Scott, D.O.

4) Palpation
General Palpation
1. Begin with light palpation. At this point you are mostly looking for areas of
tenderness. The most sensitive indicator of tenderness is the patient's facial
expression (so watch the patient's face, not your hands). Voluntary or
involuntary guarding may also be present.
2. Proceed to deep palpation after surveying the abdomen lightly. Try to
identify abdominal masses or areas of deep tenderness.
3. Video Links:
http://medinfo.ufl.edu/other/opeta/abdo/AB_ch6.html
http://medinfo.ufl.edu/other/opeta/abdo/AB_ch7.html

Palpation of the Liver

Standard Method
1. Place your fingers just below the right costal margin and press firmly.
2. Ask the patient to take a deep breath.
3. You may feel the edge of the liver press against your fingers. Or it may
slide under your hand as the patient exhales. A normal liver is not tender.
4. Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch8.html

Alternate Methods
This method is useful when the patient is obese or when the examiner is small
compared to the patient.
1.
2.
3.
4.

Stand by the patient's chest.

"Hook" your fingers just below the costal margin and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your fingers.

Liver scratch Test

5.
6.
7.
8.
9.

Used to assist in finding the lower margin of liver:

Place stethoscope over liver
Begin scratching in upward direction from abdominal area
Increase sound intensity identifies lower border of liver
Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch8.html

3 G.J.Scott, D.O.

Palpation of the Aorta

1. Press down deeply in the midline above the umbilicus.
2. The aortic pulsation is easily felt on most individuals.
3. A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic
aneurysm.

Palpation of the Spleen

1.
2.
3.
4.
5.

Use your left hand to lift the lower rib cage and flank.
Press down just below the left costal margin with your right hand.
Ask the patient to take a deep breath.
The spleen is not normally palpable on most individuals.
Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch9.html

Special Tests
Tests for Ascites
a) Shifting Dullness
This is a test for peritoneal fluid (ascites). **
1. Percuss the patient's abdomen to outline areas of dullness and
tympany.
2. Have the patient roll away from you.
3. Percuss and again outline areas of dullness and tympany. If the
dullness has shifted to areas of prior tympany, the patient may have
excess peritoneal fluid. [5]
4. Video link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch13.html

b) Fluid Wave / Succussion Splash

This is a test for peritoneal fluid (ascites). **
1. Ask pt or assistant place the edges of both hands firmly down the
midline of abdomen.
2. This pressure helps stop transmission of a wave through fat
3. Tap one flank firmly with your fingertips.
4. Feel on the opposite flank for an impulse transmitted through the fluid

4 G.J.Scott, D.O.

Murphys Sign
1. Right upper quadrant pain often suggests Acute Cholecystitis
2. Place your hands firmly in the right upper quadrant along inferior
margin of liver
3. Have patient take a deep breath
4. Watch patients breathing and degree of tenderness
5. A sharp increase in pain and abrupt cessation of inspiratory effort
is a Positive Murphy Sign and suggests Acute Cholecystitis.
6. Hepatic tenderness is also increased with this test but is less well
localized.

Costovertebral Angle Tenderness (Lloyds Sign)

CVA tenderness is often associated with renal disease (pyelonephritis,
kidney stones). **
1.
2.
3.
4.
5.
6.
7.
8.

Warn the patient what you are about to do.

Have the patient sit up on the exam table.
Place the ball of one hand in the costovertebral angle
Strike this hand with your fist
Use enough force to cause a painless perceptible jar to patient
Presence of pain is a positive sign
Compare the left and right sides.
Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch12.html

Rebound Tenderness
This is a test for peritoneal irritation / appendicitis. **
1. Warn the patient what you are about to do.
2. Pain in appendicitis classically begins near the umbilicus
3. The pain shifts to the right lower quadrant to a point between
ASIS and umbilicus called Mc Burneys Point.
4. Press deeply in the RLQ at Mc Burneys point with your hand.
5. After a moment, quickly release pressure.
6. If it hurts more when you release, the patient has rebound
tenderness. [4] Rebound Tenderness
7. Can use same technique in all areas of abdomen to check for
peritoneal irritation
8. Used to detect Acute Appendicitis
9. Video Link:
10. http://medinfo.ufl.edu/other/opeta/abdo/AB_ch10.html

5 G.J.Scott, D.O.

Rovsigs Sign
This is a test for peritoneal irritation/ appendicitis. **
1. Warn the patient what you are about to do.
2. Press deeply on the left lower quadrant of the abdomen with
your hands.
3. If palpation of the patients left lower quadrant results in more
pain in the right lower quadrant, the patient is said to have a
positive Rovsings sign and may have appendicitis. [4]

Psoas Sign
This is a test for appendicitis. **
1.
2.
3.
4.

Place your hand above the patient's right knee.

Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign.
Video link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch14.html

Obturator Sign
This is a test for appendicitis. **
1.
2.
3.
4.

Raise the patient's right leg with the knee flexed.

Rotate the leg internally and externally at the hip.
Increased abdominal pain indicates a positive obturator sign.
Video Link: http://medinfo.ufl.edu/other/opeta/abdo/AB_ch14.html

Notes:
1. For more information refer to A Guide to Physical Examination and History
Taking, Tenth Edition Chapter 11pgs.416-469 by Barbara Bates, published by
Lippincott.
2. Auscultation should be done prior to percussion and palpation since bowel
sounds may change with manipulation. When ausculting the abdomen for bowel
note that bowel sounds are transmitted widely in the abdomen, and auscultation of
more than one quadrant for bowel sounds is not usually necessary. If you hear
them, they are present, period however you should still auscultate all 4 quadrants
for bruits.
3. Additional Testing - Tests marked with (**) are usually only done when an
abnormality is suspected and can beskipped unless an.
4. Tenderness felt in the RLQ when palpation is performed on the left is called
Rovsing's Sign and suggests appendicitis. Rebound tenderness referred from the
left to the RLQ also suggests this disorder.
5. Small amounts of peritoneal fluid are not usually detectable on physical exam.
6 G.J.Scott, D.O.