Task

Abdominal Examination

Anatomic LandmarksAnterior Xiphoid process to symphysis pubis Inguinal ligaments Anterior superior iliac spines Costal marginsPosterior 11th and 12th ribs Costovertebral angleOther Mid-axillary and mid-clavicular lines

Proper Positioning Supine, flat on table - insert hand under back to check Arms at sides or folded across chest not overhead Before exam, have patient point to areas of pain Monitor exam by watching patients face for signs of discomfort Examine from right side (systematic, traditional, etc.)

Inspection-Auscultation-Percussion-Palpation is the proper order for an abdominal exam.Inspection - Skin note scars, striae, dilated veins, rashes and lesions. Umbilicus contour, location, any inflammation or bulges. Contour of the abdomen symmetry, is the abdomen flat, rounded, protuberant, or scaphoid (markedly concave or hollowed)? Are there visible organs or masses? Look for an enlarged liver or spleen that has descended below the rib cage. Bulging flanks - ascites. Pulsations normal aortic pulsation is frequently visible in the epigastrum, RV, liver, other.

Auscultation - Listen for abdominal sounds with the diaphragm of the stethoscope in all four abdominal quadrants before any palpation or percussion. Normal sounds consist of clicks and gurgles, approximately 3 34 times per minute.

Auscultation for abdominal bruits (over the aorta, illiac arteries and the femoral arteries).Percussion General:Assess amount and distribution of gas, identify masses (tympany vs. dullness) Specific: Assess size of liver and spleen Traubes space left costal margin, mid-axillary line, 6th ICS Shifting dullnessPercuss the abdomen in all four quadrants (at least these 4 locations, more if there is a problem). Can go from top to bottom or bottom to top. Will mostly hear tympany, but will hear dullness from fluid and feces.

Start at a level below the umbilicus (in an area of tympany, not dullness). Lightly percuss upward toward the liver. Ascertain the lower border of the liver dullness in the midclavicular line. Next, identify the upper border of liver dullness in the midclavicular line. Lightly percuss from lung resonance down toward liver dullness. Now measure in centimeters the distance between the two points the vertical span of liver dullness. (4-8 cm in midsternal line, 6-12 cm in right midclavicular line). Percussion of the liver span:

Percussion of Traubes Space: (two techniques for detecting splenomegaly). See arrows for suggested routes of percussing the spleen. Palpation: Palpate areas of pain last Observe face of patient for signs of discomfort Cycle of light palpation followed by deep Check for rebound tenderness Liver Spleen

Light Palpation

Deep Palpation

Palpation of the liver Palpation of the spleen

Special Tests: Scratch Test Shifting Dullness Fluid Wave Rovsings Sign Psoas Maneuver Obturator Sign Murphys Sign

Assessing for Possible Ascites

Assessing for Shifting Dullness

Assessing for a Fluid Wave