Study Guide:

With respect to skills:

Level 1 = should have confidence in performing the task and can recognize normal signs;

Level 2 = should have performed the task;

Level 3 = should have observed the task performed in real life or on video.

With respect to knowledge:

Level 1 = should understand the subject matter and can apply it to practice;

Level 2 = should have a sound understanding of the subject matter;

Level 3 = should be aware of the importance of the subject matter.

N.B. Year 1 & 2 students are expected to recognize normal findings only, although abnormal findings are also listed for students in their senior years.

• Keep the room in which you do the examination comfortably warm.

• Preserve your patient’s modesty and expose the abdomen, including the groin, only from xiphisternum to pubic symphysis.

Inspection

Exercise

• Lay the subject supine with arms by the side and pull back his clothing and bedclothes, explaining as you precede the format of your examination.
• Stand at his right side and perform a general inspection of the abdomen, noting in particular the symmetry of its shape and the presence of markings and scars.
• Lower yourself until the anterior abdominal wall is at eye level and note the shape (contour) and movement of the abdomen. Ask the patient to breathe normally while you are doing so.
• Stand up again and direct your attention to the subject’s groin bilaterally. Ask him to cough and observe for cough impulse along the inguinal canal.

Normal findings

• Skin surface

• Free of abnormal discoloration, new growth, striae, surgical scars, or prominent veins;
• Seborrhoeic warts and hemangiomas (Campbell del Morgan spots) may be normal findings in geriatric patients;
• Umbilicus is sunken (Figures 1, 2, & 4).

• Shape (contour)

• Symmetrical in shape (Figures 1 & 2);
  
  Figure 1 Figure 2
  
  
• Scaphoid or flat in young patients of normal weight (Figure 3); slightly full but not distended in older age group due to poor muscle tone or in subjects who are mildly overweight (Figures 4).
  
  Figure 3Figure 4
  

• Movement

• Rises and falls rhythmically with inspiration and expiration respectively;
• Pulsation of the abdominal aorta may be seen in the epigastrium of a slender person.

• Cough impulse

• No cough impulse should be seen along the inguinal canals.
  
  

Abnormal findings

• Skin surface

• New growths should be noted and investigated;
• Presence of striae may mean recent weight loss except in postpartum females;
• Scars may mean previous surgical operations and deserves further enquiry;
• Prominent veins are abnormal and may be due to inferior cava obstruction or portal hypertension;
• Umbilicus should still be sunken even if abdomen is distended due to obesity; umbilicus is flat or protruding in the presence of umbilical hernia or when abdomen is distended from abnormal intra-abdominal fluid collection (e.g., ascites) or masses.

• Shape or contour

• A sunken abdomen with prominent ribs and bony pelvic landmarks is seen in emaciated patients
• Symmetrical distension is seen when intra-abdominal content is increased (adipose tissue in obesity, gravid uterus, increased bowel contents like gas or fluid in bowel obstruction, peritoneal fluid in ascites);
• Gross enlargement of the liver may be seen as a bulge in the right upper quadrant;
• Gross enlargement of the spleen may be seen as a bulge in the left upper quadrant;
• Enlarged kidneys may be seen as bulges in the lumbar regions in rare occasions;
• An enlarged urinary bladder or uterus may be seen as a central rounded suprapubic swelling rising out of the pelvis.

It is not possible to name all the possible abnormalities that can be seen. Knowledge of the surface projection of abdominal organs is important.

• Movement

• Abdominal movement associated with respiration may be minimal or absent in peritonitis;
• In rare occasions, gastric peristalsis may be seen across the upper abdomen from left to right in gastric outlet obstruction;
• In bowel obstruction, vigorous small intestinal peristalsis may be seen in the center of the abdomen if the abdominal wall is very thin or if there is separation of the rectus muscles.

• Cough impulse

1. A bulge along the inguinal canal accompanying the cough may suggest the presence of an inguinal hernia but this is by no means conclusive evidence.
   
   
   

Palpation

1. It is important that you warm your hands by any convenient means before your palpate the abdomen of your patient.
2. Half flexing the patient’s hips and knees will help to relax the abdominal musculature and make palpation easier.
3. If the patient is particularly ticklish, palpate his abdomen over his hand can acclimatize him to direct palpation by the examiner.
4. There are 4 phases to palpation of the abdomen: (1) light palpation, (2) deep palpation, (3) bimanual palpation of the liver and gallbladder, spleen, and kidneys, and (4) palpation of the groin.

Light palpation

• The purpose of light palpation is to check abdominal muscle tone, tenderness, and rebound tenderness. When it is performed well it can help to gain the confidence of the patient and prepare him for deep and bimanual palpation.
• When muscle tone is increased, there is resistance to depression of the abdominal wall by the palpating hand; it commonly accompanies the presence of tenderness.
• Tenderness is pain elicited by the palpating hand when pressure is applied to the abdomen wall. It is a sign that the peritoneum under the abdominal wall or the underlying organ is inflamed.
• Rebound tenderness is pain elicited when pressure applied to the abdomen wall by the palpating hand is suddenly released. It is a sign that the underlying peritoneum is inflamed.

Exercise

1. Ask the patient if any part of the abdomen is tender. Start palpation as far from that area as possible.
2. Place the palm of your hand flat on the abdomen. Palpate gently and apply pressure by flexing the fingers in unison at the metacarpal-phalangeal joints. Check muscle tone, tenderness, and rebound tenderness as you proceed.
3. Move your hand through all regions (usually from the lower abdomen and working your way upwards) and palpate the entire abdomen without lifting your hand off its surface in a systematic manner.

Normal findings

• The normal abdomen feels soft to palpation;
• There should be no tenderness or rebound tenderness.

Abnormal findings

• Failure by the patient to relax is a common reason for increased muscle tone. This can make palpation of the abdomen difficult and be confusing to an inexperienced person. Efforts directed to making him comfortable, gaining his confidence, and distracting him (mentioned above) are helpful to alleviate this problem. Asking the patient to take slow deep breaths can also help.
• Increased in muscle tone, tenderness, and rebound tenderness are indications of organic disease. Knowledge of the surface projection of abdominal organs is helpful in deciding which organ is involved.
  
  
  

Deep palpation

• The purpose of deep palpation is to feel for organs in the depth of the abdominal cavity.
• The procedure is similar to light palpation but firm steady pressure is used. However you should avoid digging your fingers into the abdominal wall.
• Some practitioners use a two-hand approach to apply firm pressure when palpating for the caecum or sigmoid colon in the right and left iliac region respectively.

1. Place the palm of your hand flat on the abdomen. Apply firm steady pressure by flexing the fingers in unison at the metacarpal-phalangeal joints to feel for organs in the depth of the abdominal cavity.
2. As you proceed, try to coordinate the flexion-relaxation motion at the metacarpal-phalangeal joints with a motion of the palpating hand moving slightly back-and-forth across the abdomen so as to “roll” your hand over the underlying organ.
3. Move your hand through all regions and palpate the entire abdomen in a systematic manner, correlating the area you are palpating to the surface projection of the organ lying beneath.

Normal findings

• In the absence of pathology, most abdominal organs are not palpable. In slender patients with a soft abdomen the following may be palpable: the caecum in the right iliac region, the transverse colon in the epigastrium, and the colon in the left iliac region if they are filled with feces and the pulse of the aorta in the epigastrium.

Abnormal findings

• Lesions on the abdominal wall can be distinguished from those inside the abdomen by asking the patient to tighten his abdominal muscles (e.g., by asking the patient to lift his head off the pillow and look at his toes): those on the abdominal wall will remain palpable while intra-abdominal lesions are not.
• When a mass is felt, its features should be described as fully as possible:
  • Location (in the wall of or inside the abdomen; also its position according to the quadrants or regions of the abdomen and its relation to other organs).
  • Shape (round, oval, irregular, etc).
  • Size (in terms of diameters in at least 2 of the 3 dimensions).
  • Consistency (hard, firm, rubbery, soft, fluctuant, indentable, pulsating).
  • Surface texture (smooth, nodular, irregular, etc).
  • Mobility (free or fixed to adjacent tissue, movement in relation to respiration).
  • Tenderness (tender or non-tender).
  • Pulsation (When pulsation is felt it is important to determine whether it is expansile or not expansile. In expansile pulsation, the outward-inward pulsetile movement occurs in all directions. In non-expansile pulsation, the pulsetile movement occurs only in one direction. If it is expansile, the palpated mass is most likely an aortic aneurysm. If it is not expansile, the palpated mass is on top of the aorta. However, a fluid filled cyst on top of the aorta may feel expansile.)
• A clear understanding of the surface projection of abdominal organs is the best guide to determining the origin of the lesion.
  
  
  

Bimanual palpation

• Bimanual palpation should be applied to organs that move with respiration: i.e., the liver and gallbladder, kidneys, and spleen.

Exercise (liver and gallbladder)

1. Lay the patient supine and stand on his right side.
2. Slide your left hand across and behind the patient’s lowermost ribs on the right.
3. Place your other hand flat on the anterior abdominal wall, with fingers pointing upward, lateral to the rectus muscle, and just below the costal margin.
4. Simultaneously push forward with the posterior hand and press inward and upward with the anterior hand while the patient is instructed to take a deep breath through his mouth.
5. Near the peak of inspiration allow the anterior hand to rise with the abdominal wall while maintaining upward pressure. (The liver edge may be felt as it slips beneath the tip of the leading fingers or you may feel the liver moving caudad. An enlarged gallbladder may be felt half way between the xiphoid process and the flank.)
6. Repeat the about maneuver across the abdomen to trace the liver edge as it passes from the right hypochondrium to the epigastrium. (Be aware that if you start palpation too close to the costal margin, the low-lying edge of an enlarged liver may be missed.)
7. Note how far below the right costal margin is the liver edge palpable (e.g., not palpable, just palpable or palpable so many centimeters below the right costal margin
   
   Figure 6 Figure 7

N.B. Another method of palpating the liver uses the radial border of the index finger. In this method the anterior hand is placed flat on the anterior abdominal wall with fingers parallel to the costal margin. You should be aware of this alternative technique.

Normal findings

• The liver can descend for up to 3 cm on deep inspiration and its edge can be, though not always, palpable just below the right costal margin without being enlarged in many normal subjects.
• The normal liver edge is sharp, smooth, soft, and flexible.
• The normal gallbladder is not palpable.

Abnormal findings

The liver is enlarged, soft, smooth, tender in heart failure

The liver is enlarged, firm, smooth, non-tender in obstructive jaundice and the earlier stages of cirrhosis (in end-stage cirrhosis the liver is shrunken and hard).

• The liver is enlarged, hard, irregular or nodular, non-tender in liver metastasis.
• The liver is enlarged and pulsating in tricuspid regurgitation.
• The gallbladder is palpable only if it is enlarged. Mucus collected in the gallbladder due to chronic cystic duct obstruction may be felt as a round, firm, but smooth mucocele.
• Palpable gallbladder in the presence of obstructive jaundice is due to carcinoma of the head of pancrease until proven otherwise.
• Carcinoma of gallbladder presents as a hard, irregular, and non-tender swelling.
• An acutely inflamed gallbladder is exquisitely tender. During step 5 above, inspiratory effort may be arrested abruptly due to pain. This is called Murphy’s sign.

Exercise (spleen)

1. Lay the patient supine and stand at his right side.
2. Reach across the patient and place your left hand flat against his left side, supporting the lowermost portion of his rib cage posterolaterally.
3. Place the right hand flat over the left hypochondrium with fingers pointing beneath the outermost portion of the left costal margin.
4. Simultaneously press medially and downward with the left hand and inward and upward with the right hand while the patient is instructed to take a deep breath. (The lower pole of a sufficiently enlarged spleen is felt as a firm and smooth swelling with round borders as it appears beneath the costal margin at the height of inspiration.)
5. Move your right hand more medially and repeat maneuver 4 if necessary.

N.B. You should be aware of 2 other techniques of palpating the spleen used by some doctors:

• Lay the patient on his right side and repeat the maneuvers described above.
• Stand facing your supine subject on his left side at shoulder level; place you left hand flat against his lower rib cage on the left and press your fingers inward and upward beneath the costal margin while he is instructed to take a deep breath.

Normal findings

• The normal spleen in a healthy subject is not palpable.

Abnormal findings

• An enlarged spleen (splenomegaly) is always pathological. Enlargement takes place in a postero-superior direction at first; it does not appear subcostally until it is 2 – 3 times normal size.
• An enlarged spleen retains its shape, its rounded anterior edge interrupted by one or two notches, and its smooth texture. These features distinguish it from a left renal mass.
• A large spleen appears as a left upper quadrant mass that moves with respiration; it is not possible to slide an examining finger between it and the costal margin. A very large spleen crosses the mid-line and points toward the right iliac fossa. These are other features that distinguish it from an enlarged left kidney.
• Common causes of enlarged spleen (splenomegaly) are portal hypertension in liver cirrhosis, various infections (e.g., infectious mononucleosis and malaria), and the lymphomas and leukemias.

Exercise (right kidney)

1. Lay the patient supine and stand on his right side.
2. Place the flat of your left hand behind the subject’s right flank supporting the right costo-vertebral angle (also called the renal angle) lateral to the erector muscle of the spine (Figure 10).
3. Place your right palm flat across the subject’s right lumbar region at the same level as your left hand and just lateral to the rectus muscle.
4. Press the two hands together firmly and ask the patient to breath in deeply to see if you can feel the lower pole of the right kidney.
5. Sit the patient up, place your left hand flat against the costo-vertebral angle and pound on the back of your hand with your right fist to check for tenderness.

Normal findings

• The lower pole of the right kidney may be felt at the height of inspiration as a rounded smooth structure if the subject is of slender build. If the subject’s breathing and the movement of the examining hands are coordinated, it may even be possible to palpate this pole between the hands. (Unless the patient is very slender, it is unlikely that you can feel or trap the right kidney if it is normal in size. However you should be competent in this maneuver; an enlarged right kidney is palpable.)
• Pounding on the costo-vertebral angle should not cause pain.

Abnormal findings

• Features of any abnormal mass should be described: location, shape, size, surface texture, consistency, mobility, and tenderness.
• Tenderness at the costo-vertebral angle means infection or inflammation of the kidney.

Exercise (left kidney)

1. Lay the subject supine and stand on his right side.
2. Reach across him and place your left hand behind his left lumbar region (left flank) supporting the left costo-vertebral angle lateral to the erector muscle of the spine.
3. Place the right hand across the subject’s left flank opposite your left hand.
4. Press the hands firmly together while the patient is taking a deep breath in an attempt to feel the descending left kidney.
5. Sit the patient up, place your left hand flat against the costo-vertebral angle and pound on the back of your hand with your right fist to check for tenderness.

Normal findings

• It is rare that you will feel the left kidney, even in a slender subject; it sits higher up in the retroperitoneal space than the right kidney.
• Tenderness at the costo-vertebral angle is an abnormal finding.

Abnormal findings

• As for right kidney.
  
  
  

Palpation of the groins

• In the supine position, this should include feeling for femoral pulses and abnormal lymph nodes and checking for hernias. However, examination for hernias is not conclusive unless the groins are examined with the patient standing. (Proper examination for hernias will be presented in a separate session.)

Exercise

1. Stand to one side of the subject and palpate the right and left femoral artery, which lies just below the inguinal ligament mid-way between the anterior superior iliac spine and the pubic symphysis.
2. Feeling with the fingers, palpate along the femoral artery and the inguinal canal on both sides for abnormal or enlarged lymph nodes.
3. Place the palmar surface of the fingers of one hand over the inguinal canal on one side and the same with your other hand on the other side. Do not cross your arms. Check for expansile (cough) impulse in the inguinal canal while the subject coughs.

Normal findings

• The femoral pulse should be discrete and bounding. If the radial pulse is palpated at the same time, there should be no delay (i.e., the femoral pulse lagging behind the radial pulse).
• Lymph nodes are either absent or small, soft, smooth, mobile, and non-tender.
• There should be no expansile (cough) impulse in the inguinal canal while the patient coughs.

Abnormal findings

• In severe atherosclerosis affecting the aorta or femoral vessels, the femoral pulse may be absent or delayed (lags behind the radial pulse).
• Enlarged lymph nodes should be described in terms of location, shape, size, consistency, surface texture, mobility, and tenderness.
• Palpable expansile (cough) impulse in the inguinal canal while the patient coughs is indicative of inguinal hernia. However, examination for hernias is not conclusive unless the groins are examined with the patient standing.
  
  
  

Percussion

Technique of percussion

1. Spread the fingers of your left hand slightly and place the palmar surface of the middle phalanx of the middle finger flat over the spot you wish to percuss.
2. Flex the distal two phalanges of the middle finger of your right hand and use its tip to strike the middle phalanx of the middle finger of the left hand perpendicularly like a hammer. Withdraw the striking finger as soon as the stroke is delivered. Delivery of the stroke is through flexing the wrist and the finger at the metacarpo-phalangeal joint and not through any actions in the elbow or shoulder.
3. Use the slightest stroke that will produce a clear sound note.
4. Repeat the stroke until you have fully appreciated the character of the evoked sound note before you move on to the next site.

• Five sound notes may be evoked, depending on the site or underlying pathology:

• The sound note is flat when the site is over soft tissue or fluid.
• The sound note is dull when the site is over a solid organ beneath a layer of lung.
• The sound note is resonant when the site is over air-filled lung tissue.
• The sound note is hyper-resonant when the site is over air-filled pleural cavity (a condition called pneumothorax).
• The sound note is tympanitic when the site is over air-filled bowel.

Exercise

1. Percuss your thigh and listen to the evoked sound note. (The underlying tissue is fat, muscle, and bone.)
2. Percuss your right chest just under the clavicle and listen to the evoked sound note. (The underlying tissue is air-filled lung.)
3. Percuss your right chest at the right mid-clavicular line above the costal margin and listen to the evoked sound note. (The underlying tissue is lung over liver.)
4. Percuss the left upper quadrant of your abdomen below the costal margin and listen to the evoked sound note. (The underlying stomach may contain a large gas bubble.)

Percussion of the abdomen

Percussion is used to delineate the borders of the liver, the enlarged spleen, or other masses. It is also used to determine if abdominal distention is due to gas-filled bowels or accumulation of fluid (a condition called ascites). When percussion is practiced, always proceed from a tympanitic or resonant site towards a dull or flat site and position the middle finger that receives the strike parallel to the anticipated border and not perpendicular to it.

Normal findings

• To delineate the liver borders, you should start percussing along the mid-clavicular line at the 4th intercostal space. The percussion note will change from resonant to dull at the 5th intercostal space where the upper border of the liver normally lies. This dullness will continue down to or to just below the costal margin in a normal subject.

• The only area in the normal abdomen that may be tympanitic is the left upper quadrant if the stomach is filled with gas. The percussion note in the other areas is usually dull to flat.

Abnormal findings

• The upper border of the liver may shift downwards if the lungs are hyper-inflated due to air trapping in patients who have chronic airway obstruction and emphysema.

• Liver dullness may be lost in patients who have air within the peritoneal cavity (pneumoperitoneum), usually due to perforated bowel. However this is not a reliable sign if the volume of air in the peritoneal cavity is only small.

• The borders of a palpable spleen or other masses can be delineated by percussion. Areas within the borders will be dull or even flat to percussion; areas outside will be tympanitic.

• If abdominal distension is due to gas-filled bowels, the entire abdomen will be tympanitic.

• Whether abdominal distension is due to the presence of fluid (ascites) can be determined by shifting dullness:

1. Lay the subject supine and determine the fluid level at which the percussion note changes from tympanitic anteriorly to flat posteriorly in the patient’s flanks bilaterally. (In the supine position, gas-filled bowels float on top of the ascitic fluid.)
2. Turn the subject to his side and allow time for the fluid to gravitate before delineating fluid level again by percussion. (Fluid would gravitate to the dependent flank, which would sound flat to percussion while the non-dependent flank would be tympanitic.
3. Now turn the patient to the other side and repeat Step 2.

Shifting of dullness in both flanks when the patient is supine to dullness only in the dependent flank when the patient is on his side indicates the presence of ascites. The ability to demonstrate shifting dullness increases with the volume of ascetic fluid. Shifting dullness may be absent if the volume of ascetic fluid is only small.

• Another test for ascites is the demonstration of fluid thrill:

1. Lay the subject supine and place one hand flat against his flank on one side.
2. Ask an assistant (e.g., a nurse) or the patient to place the ulnar aspect of his hand firmly in the midline of the abdomen.
3. Without crossing your arms, tap the opposite flank of the abdomen with your other hand. (If ascetic fluid is present, the impulse generated by the tap will be transmitted to your hand on the flank. The hand on the abdomen is to prevent transmission of the impulse over the abdominal wall, particularly when it has a thick layer of subcutaneous fat.)

Fluid thrill is demonstrable only if a large volume of ascetic fluid is present. Absence of shifting dullness or fluid thrill or both does not rule out the presence of a small-volume ascites.

Auscultation

The purpose of auscultation of the abdomen is to listen for bowel sounds produced by peristaltic activities and vascular sounds.

Exercise

1. Rest the diaphragm of your stethoscope lightly on the right lower quadrant of the abdominal wall with a steady hand and listen for bowel sounds for at least 30 seconds. (Listening over the right lower quadrant only is adequate when bowel sounds are normal. Listening over the other quadrants are indicated when abnormalities are present.)

2. Steady the diaphragm of the stethoscope over the right upper quadrant with one hand. Shake the abdomen from side to side vigorously at the same time with the other free hand and listen for a splashing noise (succussion splash) due to wave-like motion of fluid in an air-filled cavity. (Many doctors do not practise this maneuver but you should be aware of its significance explained below.)

3. Listen for bruits (murmur-like sound that occurs during systole; associated with narrowing of the underlying artery) over the following areas:

• The abdominal aorta (A) at the epigastrium;
• The renal arteries (R) at the hypochondrium bilaterally or the costovertebral angle at the back bilaterally;
• The iliac arteries (I) in the center of each lower quadrant;
• The femoral arteries (F) just below the mid-point of the inguinal ligment bilaterally.

4. Listen for venous hum over the epigastrium. (Venous hum is associated with blood flow in venous collaterals found in portal hypertension. While aortic bruit occurs during systole, venous hum is a continuous sound softer than a bruit.)

Normal findings

• Normal bowel sounds are intermittent and heard as bursts of continuous sound every 5 to 10 seconds. They have a medium pitch and a gurgling quality, representing the movement of air and fluid through the gastrointestinal tract.

• Succussion splash may be heard in normal subjects for up to 3 hours after a meal.

• No arterial bruit is heard in the normal abdomen.

• No venous hum is heard in the normal abdomen. In fact, venous hum is rarely heard, even in patients with portal hypertension.

Abnormal findings

• In acute bowel obstruction, bowel sounds are exaggerated in intensity due to increase in peristaltic activity. The quality of the sound ranges from low pitch gurgles (borborygmi) to high pitch tinkles. Bouts of intense activity are interrupted by periods when the abdomen is silent. In later stages, bowel sounds are less frequent and may stop all together.

• In peritonitis bowel peristalsis stops (paralytic ileus) and the abdomen is silent. Paralytic ileus is also seen in patients after abdominal surgery in which the bowels have been handled during the operation.

• Succussion splash heard in a subject more than 3 hours after a meal is a sign of gastric outlet obstruction. The stomach may contain up to 2 liters of fluid and gas in this condition.

• Systolic bruit heard over an artery indicates stenosis of the underlying artery. Systolic bruit may be heard also over very vascular intra-abdominal tumors.

• Venous hum is rarely heard. When present, it is a sign of venous collaterals developed secondary to portal hypertension.