In addition, if the patient is complaining of pain, leaving the palpation until last allows the examiner to gather other data before potentially causing the patient more discomfort. When completing the physical examination, it is helpful to divide the abdomen into regions in order to consider which organs are involved.
A four-quadrant system — left upper quadrant, left lower quadrant, right upper quadrant and right lower quadrant provides a more general overview, and is acceptable in situations when there is no abdominal complaint.
The nine-region system provides more specific information if the patient is complaining of discomfort or problems in a certain area. The nine regions include the following: right hypochondriac upper region, right lumbar middle region, right iliac lower region, left hypochondriac upper region, left lumbar middle region, left iliac lower region, epigastric region, umbilical region, and hypogastric suprapubic region.
Perform auscultation before percussion and palpation because manipulating the abdominal wall may increase bowel sounds or produce sounds that are not usually present. Make sure that your hands and the stethoscope are warm so that the abdominal muscles do not contract on contact. Auscultation should be performed systematically by quadrant. Using the diaphragm of the stethoscope will allow you to hear high-pitched sounds. After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound analogous to a murmur caused by turbulent blood flow through a vessel narrowed by atherosclerosis.
The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting e. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures.
Atherosclerosis distal to the aorta i. Blood flow through the aorta itself does not generate any appreciable sound. Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation.
The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action see under lung exam.
There are two basic sounds which can be elicited:. What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin.
The spleen is smaller and is entirely protected by the ribs. To determine the size of the liver, proceed as follows:. Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally, resting in a hollow created by the left ribs. When significantly enlarged, percussion in the left upper quadrant will produce a dull tone.
Splenomegaly suggested by percussion should then be verified by palpation see below. The remainder of the normal abdomen is, for the most part, filled with the small and large intestines. Try percussing each of the four quadrants to get a sense of the normal variations in sound that are produced.
These will be variably tympanitic, dull or some combination of the above, depending on whether the underlying intestines are gas or liquid filled. The stomach "bubble" should produce a very tympanitic sound upon percussion over the left lower rib cage, close to the sternum.
Percussion can be quite helpful in determining the cause of abdominal distention, particularly in distinguishing between fluid a. Of the techniques used to detect ascites, assessment for shifting dullness is perhaps the most reliable and reproducible. This method depends on the fact that air filled intestines will float on top of any fluid that is present.
Proceed as follows:. The models below should help to clarify the concept of shifting dullness. With the "patient" lying flat on their back balloons representing the intestines float on the water representing ascites. When the "patient" turns on their right side, a new air fluid level is established.
Realize that there has to be a lot of ascites present for this method to be successful as the abdomen and pelvis can hide several hundred cc's of fluid that would be undetectable on physical exam. Also, shifting dullness is based on the assumption that fluid can flow freely throughout the abdomen. Thus, in cases of prior surgery or infection with resultant adhesion formation, this may not be a very useful technique. Palpation can also be used to check for ascites see below.
First warm your hands by rubbing them together before placing them on the patient. The pads and tips the most sensitive areas of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right.
Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel. What can you expect to feel? Find answers fast with the high-powered search feature and clinical tools. Try free for 5 days Evidence-based content, created and peer-reviewed by physicians.
Read the disclaimer. Abdominal examination. Summary A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultation , percussion, and palpation. 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 of the abdomen Note any scars, striae , vascular changes e. Purpose: to assess bowel sounds Auscultate over all four quadrants.
Listen for bruits. Normal findings : : gurgling bowel sounds every 5—10 sec Percussion of the abdomen Purpose: to determine the size and location of intra-abdominal organs Percuss over all four quadrants. 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: Superficial palpation : to assess for superficial or abdominal wall processes Deep palpation in all four quadrants : to assess intraabdominal organs potential signs of peritonitis Rebound tenderness : abrupt increase in pain when an examiner suddenly releases compression of the abdominal wall.
Caused by irritation of the receptors in parietal peritoneum Abdominal guarding : patient contraction of the abdominal wall muscles during palpation Involuntary guarding also referred to as " rigidity " : involuntary tightening of the muscles due to peritoneal inflammation and is often localized to a specific abdominal quadrant. Voluntary guarding: voluntary contraction in order to avoid pain during the examination and is often generalized over the entire abdomen. Palpation of the liver Place the pads of your fingers over the right upper quadrant , approx.
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. 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.
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