THE ABDOMINAL EXAMINATION

BENCHMARKS
The College Faculty of the University of Washington School of Medicine
Seattle, Washington

BASICS
The Abdominal Examination occurs after the heart examination in the supine patient.
The sequence of the examination should be “look, listen, and then feel.”
Insure the following whenever possible:
• The patient’s comfort is maximized
• They are supine and double draped so only their abdomen is exposed
• Their head is supported by a pillow
• Their knees are slightly flexed (to help relax the abdominal musculature—a pillow beneath
the knees assists with this)
• Their hands are on their chest or by their side
• Your hands are warm
• As you proceed, watch the patient’s face for signs of pain/distress
• The painful or tender area of the abdomen should be examined last

1. INSPECTION
DO
Observe for:
• Patient distress (does it hurt the patient to move or cough?)
• Abdominal distension, and if present, whether it is localized or generalized
• Scars
• Masses
• Visible organomegaly

KNOW
The abdomen is typically divided into 4 quadrants based on two perpendicular planes drawn through
the umbilicus: RUQ = right upper quadrant, LUQ = left upper quadrant, RLQ = right lower
quadrant, and LLQ = left lower quadrant. In addition, three middle or central regions are also
described: epigastrium, peri-umbilical, and hypogastrium (or suprapubic region).
A localized bulge in the abdominal wall may suggest a hernia (a hernia is a protrusion of an
anatomical structure through the wall that normally contains it).
Patients with peritonitis have increased pain with sudden movements of the abdomen, like
coughing, walking, or when the stretcher/bed is bumped.

2. AUSCULTATION
DO
Listen in one place with the diaphragm of the stethoscope until you hear bowel sounds.
Listen for bruits in the epigastrium and both upper quadrants in individuals at risk for atheroslerotic
vascular disease (the diaphragm of the stethoscope is adequate for this).
Auscultate over both femoral arteries for bruits in patients at risk for vascular disease.

KNOW
Normal bowel sounds (borborygmi) occur at a rate of 5-34 / minute and are generally gurgling and
relatively low-pitched.
In bowel obstruction, bowel sounds can be high-pitched and tinkling.
In complete obstruction, there may be no bowel sounds, but you may have to listen for 2 minutes to
be truly sure there are no sounds.
An isolated systolic bruit heard in the epigastrium can regularly be heard in normal persons.
3. PERCUSSION
DO
Percuss the abdomen lightly in all four basic quadrants.
Percuss, in the mid-clavicular line, the upper liver margin superiorly and the lower liver margin
inferiorly. (Alternatively, the lower liver margin may be determined by palpation—see below).
Measure the distance between the upper liver margin and the lower liver margin in the mid-
clavicular line.
If you suspect ascites (an abnormal collection of fluid in the intra-abdominal cavity) on the basis of
bilateral flank bulging or dullness to percussion, then also perform one of the following tests:
• Fluid wave
9 Have the patient place the edge of their own hand on their anterior abdominal wall to
dampen “false positive” soft tissue waves
9 Lightly place your right hand on the right lateral side of the patient’s abdomen
9 With the fingertips of your left hand, briskly tap the left lateral side of the patient’s
abdomen
9 In the presence of ascites, you will feel a “tap” against your right hand as the fluid wave
generated by your left hand travels thorough the patient’s ascitic fluid
• Shifting dullness
9 In the presence of ascites, air-filled bowel loops “float” above the ascitic fluid
9 In the supine patient, percuss the bowel-fluid level on the patient’s lateral abdominal wall
(percussing from anterior to posterior) noting where the percussion note changes from
tympanitic (bowel loops anteriorly) to dull (ascitic fluid posteriorly). With the patient’s
permission, make a small mark with your pen to delineate this line.
9 Now have the patient assume a partial decubitus position angled towards you
9 Again, percuss the lateral abdominal wall and see if the bowel-fluid interface level has
changed (by shifting anteriorly along the flank). If it has, it suggests that there is freely
moving ascitic fluid within the abdomen.

KNOW
The normal abdomen should have both tympanitic areas (gas-filled bowel) and dull areas (fluid-filled
bowel).
A protuberant abdomen that is diffusely tympanitic suggests intestinal obstruction.
Localized percussion tenderness suggests peritoneal inflammation.
The causes of ascites include liver disease, renal disease, inflammation, decreased intravascular
oncotic pressure, and right-sided or biventricular congestive heart failure.
The determination of a given patient’s liver span varies between observers. The more consistent you
are in using the same method with every patient you evaluate, the less variable your own
examination becomes in assessing liver size. Current references list different normal liver spans
in the mid-clavicular line as follows:
• Bates’ Guide to Physical Examination and History Taking: 6-12 cm
• Evidence-Based Physical Diagnosis: 6-15 cm
• Physical Diagnosis Secrets: < 12-13 cm

4. PALPATION
DO
Palpate all 4 quadrants superficially once, then palpate them again more deeply.
Palpate the lower liver edge in the right upper quadrant.
Technique:
th th
9 Place your left hand behind the patient, along and just below their 11 -12 ribs
9 Ask the patient to relax, and press your left hand forward (anteriorly)
9 Place your right hand on the patient’s right abdomen in the mid-clavicular line
9 Begin your palpation well below the lower border of liver dullness as determined by percussion in
step 3 described above (begin closer to the pelvis, and work your way sequentially and superiorly)
9 Ask the patient to breath inward as you try to feel for their liver edge coming down to meet your
right hand’s fingertips
 9 Repeat several times, keeping your left hand in the same place, but adjusting your right hand’s
position as necessary
9 If the edge is palpated, note whether it is tender to the patient; also note the characteristics of the
palpated edge: soft, smooth, or hard and nodular
Palpate for an enlarged spleen in the LUQ by using a similar technique as for liver edge palpation,
except reach across the patient with your left hand, supporting and pressing forward with your left
hand on the patient’s left lower rib cage and adjacent soft tissues. Attempt to palpate the spleen
with your right hand in the LUQ (but, as with liver palpation, begin the palpation process inferiorly
in the left lower quadrant and sequentially work your way superiorly).
Assess (via palpation) the abdominal aorta for enlargement in people aged > 50 years or those who
have risk factors for vascular disease.
Technique:
9 Press gently inward in the epigastirc region slightly left of the midline to identify aortic
pulsations
9 Now place your hands on either side of the aorta, and press inwards, attempting to
determine the width of the palpated pulsations (which are transmitted through overlying
tissue)
9 Remember that you are feeling pulsations through multiple overlying tissues—so even
the normal adult aorta (< 2.5-3.0 cm in diameter) will feel “wider” than it is. An aorta ≥ 5
cm diameter on ultrasound requires an immediate vascular surgery consultation.
Palpate the inguinal areas bilaterally for tenderness, swelling, and adenopathy.

KNOW
Peritonitis is inflammation of the peritoneum. It is typically made worse by patient movement,
abdominal wall percussion, and with palpation.
Tenderness is discomfort illicited by palpation.
Guarding is a VOLUNTARY contraction of the abdominal musculature due to tenderness, fear, the
examiner’s cold hands, or patient anxiety.
Rebound is abdominal tenderness that is worse when the palpating fingers are quickly removed from
the place of palpable tenderness (but please avoid doing this if the patient is in pain—it is too
uncomfortable).
Rigidity is an INVOLUNTARY contraction of the abdominal musculature in response to peritoneal
inflammation. Some clinicians use the term involuntary guarding instead of rigidity.
McBurney’s point is 1/3rd the distance along an imaginary line drawn from the anterior superior iliac
spine to the umbilicus; it represents the approximate position of the appendix in a non-pregnant
adult.
Murphy’s sign is a brief inspiratory arrest secondary to patient discomfort when the examiner
presses his/her fingers inward in the RUQ mid-clavicular line. It is associated with acute
cholecystitis.

Additional Examination Reminder:

A complete abdominal examination should include a genital and rectal examination.