What are the steps involved in a comprehensive abdominal exam?

Comprehensive Abdominal Examination

A thorough abdominal examination should follow a systematic approach of inspection, auscultation, percussion, and palpation to accurately detect abnormalities and guide diagnosis.

Preparation

• Position the patient supine with arms at sides
• Ensure adequate exposure from xiphoid process to pubic symphysis
• Drape appropriately for patient comfort
• Warm hands before examination
• Have patient empty bladder before examination if possible
• Explain each step to the patient

Step 1: Inspection

• Observe the abdomen from multiple angles (standing at patient's side and foot of bed)
• Note:
  • Contour (flat, scaphoid, distended, protuberant)
  • Symmetry or asymmetry
  • Visible masses or bulges
  • Skin changes (scars, striae, dilated veins, rashes)
  • Umbilicus position and appearance
  • Visible peristalsis
  • Pulsations
  • Respiratory movement of abdomen
  • Evidence of trauma (bruising, abrasions, "seatbelt sign") 1

Step 2: Auscultation

• Perform before percussion and palpation to avoid altering bowel sounds
• Use diaphragm of stethoscope
• Listen in all four quadrants for:
  • Bowel sounds: frequency, pitch, and character
    • Normal: 5-35 sounds per minute
    • Hyperactive: frequent, high-pitched (obstruction)
    • Hypoactive: infrequent (ileus)
    • Absent: listen for 5 minutes before declaring absent
  • Vascular sounds: bruits over aorta, renal arteries, iliac arteries
  • Friction rubs over liver or spleen

Step 3: Percussion

• Percuss systematically in all four quadrants
• Identify:
  • Tympany (air-filled structures)
  • Dullness (solid organs, masses, fluid)
  • Liver span (normal 6-12 cm in midclavicular line)
  • Splenic dullness
  • Shifting dullness (suggests ascites)
  • Costovertebral angle tenderness
  • Free air (loss of liver dullness may indicate pneumoperitoneum) 1

Step 4: Palpation

• Begin with light palpation in all four quadrants
  • Depth: 1-2 cm
  • Note areas of tenderness, guarding, or masses
• Progress to deep palpation
  • Depth: 4-6 cm
  • Assess for organomegaly and masses
• Special maneuvers:
  • Liver palpation: place left hand behind right lower ribs, right hand below right costal margin; have patient take deep breath
  • Spleen palpation: place left hand behind left lower ribs, right hand below left costal margin; have patient take deep breath
  • Kidney palpation: bimanual technique with one hand posteriorly elevating flank
  • Assess for rebound tenderness: press deeply and release quickly, positive if pain on release
  • Check for involuntary guarding (suggests peritonitis) 1

Specific Assessments

• Abdominal tenderness: note location, severity, and whether localized or diffuse
• Peritoneal signs: involuntary guarding, rigidity, rebound tenderness 1
• Murphy's sign: arrest of inspiration during deep palpation under right costal margin (suggests acute cholecystitis)
• McBurney's point tenderness: maximum tenderness at point 1/3 distance from anterior superior iliac spine to umbilicus (suggests appendicitis)
• Rovsing's sign: pain in right lower quadrant when left lower quadrant is palpated (suggests appendicitis)
• Psoas sign: pain with extension of right hip (suggests retrocecal appendicitis)
• Obturator sign: pain with internal rotation of flexed right hip (suggests pelvic appendicitis)
• Cullen's sign: periumbilical ecchymosis (suggests hemorrhagic pancreatitis)
• Grey Turner's sign: flank ecchymosis (suggests retroperitoneal hemorrhage)

Digital Rectal Examination

• Assess for:
  • Masses or tenderness
  • Prostate examination in males
  • Stool: presence, consistency, color, occult blood 1

Special Techniques

• FAST examination (Focused Assessment with Sonography for Trauma): used in trauma settings to detect free fluid 1
• Assess for ascites:
  • Shifting dullness: percuss from resonance to dullness, mark boundary, have patient roll to side, re-percuss
  • Fluid wave: tap one side of abdomen while feeling wave on opposite side

Documentation

• Record all findings systematically by quadrant
• Note presence or absence of:
  • Tenderness (location, severity, character)
  • Masses (location, size, consistency, mobility, tenderness)
  • Organomegaly
  • Abnormal sounds
  • Peritoneal signs

Clinical Pearls

• Peritoneal signs may take several hours to develop in bowel perforation 1
• Serial examinations increase accuracy when monitoring patients with suspected intra-abdominal pathology 1
• Significant abdominal tenderness and involuntary guarding suggest peritonitis and possible leakage of intestinal contents 1
• In trauma patients, the "seatbelt sign" should alert to possible intra-abdominal injury 1
• The order of auscultation (before or after palpation/percussion) does not significantly affect bowel sound frequency 2
• In unconscious patients, tolerance to enteral feeding may serve as an indicator of bowel integrity 1

This systematic approach ensures a thorough examination that can guide further diagnostic testing and management decisions.