Proper Technique for Per Abdomen Examination
The per abdomen examination should follow a systematic approach of inspection, auscultation, percussion, and palpation in that specific order to avoid altering bowel sounds and causing patient discomfort.
Patient Preparation
- Position patient supine with arms at sides
- Expose abdomen from xiphisternum to symphysis pubis
- Place a small pillow under the head and knees to relax abdominal muscles
- Ensure warm hands and short fingernails
- Ensure adequate lighting and patient comfort
- Empty bladder before examination if possible
Systematic Approach
1. Inspection (First)
- Observe from the foot of the bed at eye level
- Note:
- Abdominal contour and symmetry
- Visible pulsations or peristalsis
- Skin changes (scars, striae, dilated veins, rashes)
- Umbilicus position and appearance
- Any visible masses or distention
2. Auscultation (Second - Before Percussion and Palpation)
- Listen with diaphragm of stethoscope in all four quadrants
- Note bowel sounds (frequency, character, hyperactive, hypoactive)
- Listen for bruits over major vessels (aorta, renal, iliac)
- Normal bowel sounds: 5-30 gurgling sounds per minute
- Spend at least 30 seconds per quadrant
3. Percussion (Third)
- Use indirect percussion technique (middle finger of non-dominant hand placed firmly on abdomen, strike with middle finger of dominant hand)
- Percuss systematically in all four quadrants
- Note areas of tympany (gas-filled) versus dullness (solid organs/fluid)
- Assess liver span (normal 6-12 cm in midclavicular line)
- Assess for shifting dullness if ascites suspected
- Percuss splenic dullness (9th-11th ribs in left midaxillary line)
4. Palpation (Last)
Light palpation:
- Begin away from area of pain
- Use light pressure with pads of fingers
- Assess all four quadrants for tenderness, guarding, masses
- Note any involuntary guarding
Deep palpation:
- Use firmer pressure with flat of hand
- Palpate systematically through all quadrants
- Assess for masses, organomegaly, tenderness
Specific organ palpation:
- Liver: Place left hand behind right lower ribs, right hand below right costal margin; ask patient to take deep breath while palpating for liver edge
- Spleen: Similar technique on left side with patient in right lateral position if needed
- Kidneys: Bimanual palpation with one hand posteriorly, one anteriorly
- Aorta: Palpate pulsations in epigastrium
Special Techniques
- Rebound tenderness: Press deeply and release quickly to assess peritoneal irritation
- Murphy's sign: Hook fingers under right costal margin, ask patient to inhale deeply (positive if pain/breathing arrest occurs)
- Rovsing's sign: Press left lower quadrant, pain in right lower quadrant suggests appendicitis
- Psoas sign: Pain with extension of right hip suggests retrocecal appendicitis
Graded Compression Technique for Ultrasound
For patients requiring ultrasound assessment, the graded compression technique should be used, particularly for appendicitis evaluation 1:
- Apply gradual increasing pressure with transducer to displace bowel gas
- Use high-frequency (5-17 MHz) linear transducer
- Perform overlapping vertical sweeps in systematic pattern
- Normal bowel wall thickness is <4mm 1
Documentation
Document all findings systematically, including:
- Abdominal contour
- Bowel sounds
- Areas of tenderness/guarding
- Palpable organs or masses
- Results of special maneuvers
Common Pitfalls to Avoid
- Examining painful areas first (increases guarding)
- Cold hands (causes voluntary muscle guarding)
- Performing palpation before auscultation (alters bowel sounds)
- Inadequate exposure of abdomen
- Failing to observe patient's face during examination
- Pressing too deeply during initial palpation
Following this systematic approach ensures a thorough abdominal examination that can detect abnormalities and guide further diagnostic evaluation while minimizing patient discomfort 1.