• Clinical science

Abdominal examination

Abstract

A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultation, percussion, and palpation. The examination begins with the patient in supine position, with the abdomen completely exposed. The skin and contour of the abdomen are inspected, followed by auscultation, percussion, and palpation of all quadrants. Depending on the findings or patient complaints, a variety of examination techniques and special maneuvers can provide additional diagnostic information.

Suggested sequence

Positioning

  • Instruct the patient to lie down and expose the patient's abdomen.
  • If your hands are cold, warn the patient prior to palpating the abdomen.

Inspection

  • Note any scars, striae, vascular changes (e.g., caput medusae), or protrusions
  • Note the general contour of the abdomen

Auscultation

Auscultation of the abdomen should be performed prior to percussion and palpation, as physical manipulation of the abdomen may induce a change in bowel sounds.

  • Purpose: to assess bowel sounds
  • Auscultate over all four quadrants.
  • Listen for bruits.
  • Normal findings: : gurgling bowel sounds every 5–10 sec

Percussion

  • Purpose: to determine the size and location of intra-abdominal organs
  • Percuss over all four quadrants.
  • Normal findings: tympanic sound over air-filled stomach/intestinal sections; muffled sounds over fluid-filled or solid organs (liver, spleen)

Palpation

  • Purpose: to evaluate internal organs and identify any sources of pain (if present)
  • Prior to palpation, ask the patient whether they have abdominal pain or tenderness. If so, begin palpation in the non-painful area.
  • Observe the patient's face during abdominal palpation, as it is the main indicator of the intensity and location of pain.
  • Procedure:
    1. Superficial palpation: to assess for superficial or abdominal wall processes
    2. Deep palpation in all four quadrants: to assess intraabdominal organs
    3. Palpation of the liver
      • Place the pads of your fingers over the right upper quadrant, approx. 10 cm below the costal margin at the mid-clavicular line. Palpate as you move towards the right upper quadrant and attempt to feel for the edge of the liver. Continue until you feel the liver or reach the costal margin.
      • Asking the patient to take a deep breath may facilitate palpation of the liver, as the movement of the diaphragm will move the liver toward your hand.
    4. Palpation of the spleen
      • Place the pads of your fingers lateral to the belly button and palpate as you move towards the left upper quadrant. Repeat 10 cm below the left costal margin.
      • Asking the patient to lie on their right side may facilitate palpation of an enlarged spleen.
    5. Palpation of the inguinal lymph nodes (see examination of the lymph nodes)

Abdominal tenderness may be a sign of numerous conditions (see differential diagnosis of acute abdomen and differential diagnoses of abdominal pain).

Liver Size

  • Percussion
    • Place the middle finger of your non-dominant hand against the abdominal wall. With the tip of the middle finger of your dominant hand, strike the distal interphalangeal joint 2–3 times.
    • Start below the breast at the midclavicular line. Percuss as you move your hand downward and note the sound change as you transition from lung (resonant) to liver (dull). Continue until the sound changes again after the inferior margin of the liver.
  • Liver scratch test
  • Normal findings: : The normal craniocaudal liver size is 7–11.5 cm in women; and 8–12.5 cm in men. In most patients, the liver is fully covered by the ribs.

Special tests

Differential diagnoses of abdominal pain

Common causes of abdominal pain (based on location)

Abdominal pain Right-sided Center Left-sided
Upper abdomen
Mid abdomen
Lower abdomen

Causes of diffuse or generalized abdominal pain

Causes of acute abdomen