PALPATION (superficial & deep)

Determine if there is tenderness on any of the abdominal quadrants

Determine if there liver or spleen is palpable (or is there any
organomegaly)
Determine if there is any palpable mass (pulsatile vs non-pulsating)
Perform how to elicit rebound tenderness
Perform bimanual exam (for kidneys)

SPECIAL MANUEVERS
I cant remember any right now =)

Student is able to summarize the significance of his/her findings to the

patient
Lastly, student is able to excuse himself/herself courteously & at the same
time giving proper assurance that patients concerns will be taken care of

OBJECTIVE STRUCTURED CLINICAL EXAMINATION

PHYSICAL EXAMINATION OF THE ABDOMEN
CHECKLIST
NAME:_____________________
SCORE:__________
BONUS
POINTS:___
SKILL
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INTRODUCTORY PHASE
Introduce self
Explain procedure
Assure patient about confidentiality
Establish rapport
ENVIRONMENT
Ensure good lighting
Make sure there is enough privacy provided
INSPECTION
Examiner asks patient to lie comfortably
supine on bed or examining table, with the
knee flexed and then stands on the
patients right side.
Drape patient appropriately. Adequate
exposure of the abdomen is necessary from
above the xiphoid process down to the
symphysis pubis, with the groin visible, and
the genitalia draped.
Instruct patient to place arms on both sides
or folded across the chest
Examiner takes note of skin turgor,
discoloration,
dilated
vessels
(caput
medusa), presence of striae, lesions,
rashes or scars (especially post-surgical
scars)
Take note appearance of umbilical contour,
location and presence of inflammation or
bulges
Take note of the contour of the abdomen (is
it Flat,
Rounded, Protuberant or scaphoid?) Do the
flanks bulge? Any local bulges? Check
inguinal/ femoral areas
Is the abdomen Symmetric? Are there any
visible organs or masses?
Observe
for
peristalsis
and
visible
pulsations

P
C

RIS

NP

REMARKS

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AUSCULTATION
Examiner warms the diaphragm of the
stethoscope before gently placing it over
the patients abdomen
Listen for bowel sounds, note frequency
and character
Listen for bruits, friction rub or any vascular
sounds
PERCUSSION
Percuss lightly in all four quadrants to
assess distribution and amount of gas in
the abdomen
Identify masses whether solid or fluid filled
Assess liver span (Estimate size) by
percussing the Right lower anterior chest
midclavicular line (from resonant to
dullness) to determine the upper border of
the liver and percussing the right side of
the abdomen midclavicular line going up
(from tympany to dullness) to assess the
lower border of the liver.
Assess size of the spleen. Percuss L lower
anterior chest wall between lung resonance
above and the costal margin to determine
the Traubes space. Note the lateral extent
of tympany. Percuss the lowest interspace
in the left anterior axillary line. This area is
usually tympanitic. Ask the patient to take
a deep breath, and percuss again
Perform the kidney punch test (or
goldflams) by fist percussion using the
dominant hand on top of the other hand
with the ball of the less dominant hand
touching the lower back of the patient over
the costovertebral angle to elicit
tenderness.
PALPATION
Be sure to warm hands before touching
patients abdomen
Liver. Place Left hand behind the patient,
parallel to and supporting the right 11th
and 12th ribs and adjacent soft tissues
below. Ask the patient to relax on your
hand. Press L hand forward and place R
hand on the patients R abdomen lateral to
the rectus muscle with the fingertips below
the lower border of liver dullness, press
gently in and up.
Ask the patient to take a deep breath and
feel the liver edge as it comes down. Trace
the liver edge laterally and medially. Try
hooking technique by standing to the

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right of the patients chest, with hands

placed side by side, on the right abdomen
below the border of liver dullness. Press in
with your fingers and up toward the costal
margin. Ask the patient to take a deep
breath
Once you feel it, lighten pressure of
palpating hand slightly so that the liver can
slip under your finger pads and you can
feel its anterior surface.
Note any
tenderness. Look for masses.
Spleen. Using the left hand, examiner
reaches over and around the patient to
support and press forward the lower left rib
cage and adjacent soft tissue. Right hand is
placed below the left costal margin, and
pressed in toward the spleen. Ask the
patient to take a deep breath. Feel the tip
or edge of the spleen as it comes down to
meet your fingertips. May also be
performed with the patient lying on her
right side. Note any tenderness, assess
splenic contour, and measure the distance
between the spleens lowest point and the
left costal margin.
Palpate for other organs:
Kidneys (by employing use of both
hands) and bladder (if distended)
and check for tenderness
Aorta - Press firmly deep in the
upper abdomen, slightly to the left
of the midline, and identify the
aortic pulsations
SPECIAL TECHNIQUES

FOR ASCITES
Shifting dullness. Perform by
percussing the patients epigastrium to
the level of dullness with the patient
lying supine. Mark borders. Ask patient
to turn onto one side on his/ her right.
Percuss and mark the borders again,
with the dullness shifting to the more
dependent side, while tympany shifts
to the top
Fluid wave. Ask the patient to press the
edges of both hands firmly down the
midline of the abdomen while the
examiner tap one flank sharply, with
her/his fingertips, feel on the opposite
flank for an impulse transmitted
through the fluid.
FOR ACUTE APPENDICITIS

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Rebound tenderness
By applying pressure over the different
quadrants of the abdomen, ask patient
if pain is felt more when the pressure is
applied or when it is released.
Rovsings
Apply pressure over the left lower
quadrant of the abdomen and then ask
patient if any pain is felt on the other
side (right lower quadrant)
Psoas
With the patient lying supine with the
knees extended, apply pressure over
the patients right anterior thigh and
then instruct patient to flex knee on
that side or resist pressure applied on
to the same thigh. Ask patient if pain is
felt on the right lower quadrant.
Obturator
Assist the patient as he/ she bends the
right knee. With the knee flexed and
right leg extended, rotate hip medially
and check if pain is elicited on the right
lower quadrant
Cutaneous hyperesthesia
Touch or apply light pressure directly
over the right lower quadrant. Inquire
from patient if there be any pain even
on slightest touch over the area.
FOR ACUTE CHOLECYSTITIS
Murphys sign
Ask the patient to take a deep breath,
while simultaneously applying pressure
(using the ball of your fingers) over and
deep to the right upper quadrant
region along the midclavicular line.
Note for a sharp increase in tenderness
with a sudden stop in inspiratory effort
on the patient.
FOR VENTRAL HERNIAS
Ask the patient to lift the head and the
shoulders off the bed then check for
presence of bulging over the anterior
abdomen and describe it
Passing Score:

CHECKLIST SCORE:

TOTAL SCORE:
LEGEND:
Performed Correctly (P.C.) (R.I.S.) - 1 point; Not Performed (N.P.) - 0 pts

2 points; Requires Further Instruction and Supervision

Instructor's Name and Signature_____________________________

___________________________

Student's Name