What are the steps for a step-by-step abdominal exam?

Step-by-Step Abdominal Examination

A comprehensive abdominal examination should follow a systematic approach including inspection, auscultation, percussion, and palpation to accurately assess abdominal pathology and guide clinical decision-making.

Preparation

• Position the patient supine with arms at sides and knees slightly flexed to relax abdominal muscles 1
• Ensure adequate exposure from xiphoid process to pubic symphysis while maintaining patient dignity 1
• Warm hands before touching the patient to prevent reflex muscle guarding 1
• Have the patient empty their bladder before examination if possible 2

Step 1: Inspection

• Observe the abdomen from multiple angles (standing at patient's side and foot of bed) 1
• Note abdominal contour (flat, scaphoid, distended, or protuberant) 1, 3
• Look for visible peristalsis, pulsations, or masses 1
• Observe for surgical scars, striae, dilated veins, rashes, or discoloration 3
• Note any asymmetry or localized bulging 1

Step 2: Auscultation

• Perform before percussion and palpation to avoid altering bowel sounds 1
• Use diaphragm of stethoscope placed lightly on abdomen 3
• Listen in all four quadrants for at least 30 seconds each 1
• Note bowel sound characteristics (normal, hyperactive, hypoactive, or absent) 1
• Listen for bruits over aorta and renal, iliac, and femoral arteries 3

Step 3: Percussion

• Percuss all four quadrants systematically 1
• Identify areas of tympany (gas-filled) versus dullness (solid organs or fluid) 1
• Assess liver span by percussing upper border at right midclavicular line (usually at 5th intercostal space) and lower border (usually at costal margin) 3
• Assess splenic dullness in left upper quadrant 3
• Percuss for shifting dullness if ascites is suspected 1

Step 4: Palpation

• Begin with light palpation of all four quadrants using the pads of fingers 1, 3
• Note any areas of tenderness, guarding, or rigidity 1
• Proceed to deep palpation using one hand on top of the other 3
• Palpate systematically in all four quadrants 1
• Specifically examine for:
  • Liver edge below right costal margin 3
  • Spleen tip below left costal margin 3
  • Kidneys (bimanual examination) 1
  • Aortic pulsation and width in epigastrium 3
  • Bladder if distended above pubic symphysis 2
  • Any masses or abnormal findings 1

Step 5: Special Maneuvers

• Murphy's sign: Ask patient to take deep breath while palpating right upper quadrant under costal margin (positive if breathing halts due to pain in acute cholecystitis) 3
• Rebound tenderness: Press deeply and release quickly (positive if pain on release suggests peritoneal irritation) 3
• Rovsing's sign: Palpate left lower quadrant (positive if pain felt in right lower quadrant suggests appendicitis) 3
• Psoas sign: Have patient flex hip against resistance (positive if painful in appendicitis) 3
• Obturator sign: Flex hip and knee, then internally rotate hip (positive if painful in appendicitis) 3

Special Considerations

• In patients with acute abdominal pain, examine the most painful area last 4
• Consider examining patient in different positions (standing, lateral decubitus) if specific pathology is suspected 1
• For pelvic assessment, consider transvaginal ultrasound with empty bladder or transabdominal ultrasound with full bladder if indicated 2
• Document all findings systematically, including location and characteristics of any abnormalities 2

Common Pitfalls to Avoid

• Failing to adequately expose the abdomen 1
• Performing percussion or palpation before auscultation (may alter bowel sounds) 1
• Cold hands causing reflex guarding 1
• Palpating too deeply too quickly, causing unnecessary pain 3
• Missing subtle findings by not examining systematically 1
• Failing to correlate physical findings with patient's symptoms 4