Master the Abdominal Exam

When I did my first abdominal exam all I could think was “I hope she’s not ticklish.” I can’t even remember if I did it right.

Abdominal pain is one of the most common complaints in family practice, so I knew I had to figure it out! Writing out this list and creating an abdominal pain map by region, helped me feel more solid in my abdominal assessment skills.

Hopefully, this review helps you too.

Stay tuned to the end to download your free printable: Mapping Out Abdominal Pain by Region

Index

First Things First

Patho . . . ugh! I know but we have to get you grounded and knowledgeable about what’s on the inside first. And patho is the only way to do that.

Here’s a quick and painless review of the solid and hollow viscera.

1. Solid Viscera

• Liver
• Spleen
• Pancreas
• Kidneys

LIVER

• Largest internal organ
• Largest gland: detoxification, protein synthesis, production of biochemical for digestion (bile)

SPLEEN

• Structure is like a large lymph node
• Functions as part of the immune system, attacking foreign antibodies and diseases
• Filters old/dying RBCs
• Holds reserve of blood
• Recycles iron

PANCREAS

Produces:

• Insulin
• Glucagon
• Somatostatin
• Pancreatic polypeptide
• Pancreatic juice = digestive enzymes for the small intestines

KIDNEYS

• Urinary system: sifting and removing waste and extra water
• Control blood pressure
• Make erythropoietin, which tells bone marrow to make red blood cells (very cool!)
• Make the active form of Vitamin D
• Control pH levels

2. Hollow Viscera

• Stomach
• Gallbladder
• Small Intestine
• Colon
• Bladder

STOMACH

• Rounded, highly elastic
• Churns food, muscular contractions
• Secrets digestive enzymes and hydrochloric acid

GALLBLADDER

• Stores and concentrates bile produced by liver
• Releases bile into the small intestine in order to digest lipids

SMALL INTESTINE

• Majority of digestion and absorption of nutrients happens in the small intestines
• This is where bile and pancreatic juices work
• Three sections: duodenum, jejunum, ileum

COLON

• Large intestine
• Removes water, salt, and some nutrients
• Forms stool
• Muscular contractions (peristalsis)
• Four sections: ascending, transverse, descending, sigmoid

BLADDER

• Elastic muscular sac
• Stores urine

3. Hands-on Abdominal Exam

Inspection

• Inspection of the abdomen always comes first!
• Place patient in the supine position with a pillow under head/knees and arms at sides. Patient will remain supine for the entire abdominal exam.
• Start by standing on the right side of the patient. To inspect, lean down so you’re parallel to the abdomen. Here you’re looking for distention, pulsations, symmetry, or visible masses.
• Stand back up and observe the abdomen from above for striae, scars, moles, discoloration and, again, for symmetry, pulsations, masses, or lesions.
• Move to the patient’s feet.
• Ask patient to lift up their head while you observe the abdomen for hernia or masses. You’re looking for rectus diathesis (separation of the rectus muscle) too.
• When documenting, the abdomen should be flat, symmetrical, with even contour, and without aortic pulsations. The skin should be warm/dry, with no scarring/masses/lesions, and the umbilicus should be midline without discoloration or infection, striae or freckles (macules) may be noted.

Auscultation

• Remember, auscultation of the abdomen always comes after inspection.
• Use the diaphragm of the stethoscope to listen to bowel sounds and the bell to listen for bruits.
• Start at the RIGHT LOWER QUADRANT every time.
• Bowel sounds: Barely rest stethoscope on the skin, especially babies, toddlers, and children.
• Move clockwise, listening for several minutes in each quad.
• Bowel sounds can be normoactive, hyperactive, or hypoactive.
• The verbiage used for documentation: gurgling, rushing, cascading, tingling.
• Auscultation of the abdomen should begin at the ileocecal valve (RLQ) and bowel sounds should be active in all 4 quadrants.
• High-pitched, frequent bowel sounds are associated with small bowel obstruction.
• Normal bowel sounds are gurgling every 5-10 seconds.
• Use the bell of the stethoscope to listen for bruits (swishing sounds produced by turbulent blood flow)
  • over the aorta (midline, about two-finger widths above umbilical)
  • the renal arteries (right and left)
  • the iliac arteries (right and left)
  • the femoral pulses (right and left)
• Auscultation over the aorta, renal arteries, iliac arteries, femoral pulses, and umbilici should always be without bruit.
• Use the bell of the stethoscope to listen for friction rubs over the liver and spleen.

Percussion

• Percussion will begin in the RLQ.
• Percuss one quadrant at a time.
• Normal findings will be a tympanic sound over the air-filled structures of the stomach and small intestines and muffled sounds over the fluid-filled/solid organs like the liver and spleen.
• To percuss the liver border, begin distally ON THE RIGHT SIDE at the mid-clavicular line and move caudally (toward the head). There will be a change in resonance from tympanic to dull, this is normal.
• To percuss the spleen border start just beyond the LEFT axillary line where dullness will change to tympani. Have the patient take a deep breath and tympani turns to dullness again, this is normal.
• A full bladder can be percussed if needed but is usually deferred.

Palpation

• Before you palpate ALWAYS ASK the patient if there is pain or tenderness anywhere in the abdomen. If so, begin palpation in the non-tender area.
• Always observe the patient’s face during palpation as a key indicator for location and intensity of pain and tenderness.
• Superficial (light) palpation comes first. Use one hand to palpate for distention, masses, hernias, tenderness, and warmth of the skin.
• Deep palpation is next. Use two hands, one over the other, to palpate the intraabdominal organs: the liver and spleen.
• Palpation of the liver border at the RIGHT mid-clavicular line at the costovertebral angle (CVA) may barely be felt.
• Palpation of the spleen at the LEFT mid-clavicular line at the costovertebral angle (CVA) cannot be felt, this is normal.
• Palpation of the kidneys is done by placing your right hand behind the patient (as you’re standing on their left side) between the rib cage and iliac crest while also placing your left hand below the left costal margin. Ask the patient to take a deep breath, while you press your hands firmly together and attempt to feel the lower pole of the left kidney. Repeat the same maneuver for the right kidney.
• Note if there is involuntary guarding, known as “rigidity.” This is usually localized to a specific quadrant of the abdomen and may be a sign of peritoneal inflammation. If involuntary guarding is noted, DO NOT continue further deep palpation.
• Also note voluntary guarding which is when the patient squirms to avoid abdominal pain, this is usually generalized over the entire abdomen.
• Palpate the inguinal lymph nodes before you move on to percussion.

Be sure to download your FREE printout: Mapping Out Abdominal Pain by Region.

Leave questions in the comments or shoot me an email!

Cheers!

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