Correct Order for Abdominal Examination
The correct order for performing an abdominal examination is: Inspection, Auscultation, Percussion, and then Palpation (IAPP). 1
Rationale for the IAPP Sequence
The IAPP sequence is specifically designed to prevent alteration of abdominal findings during the examination:
Inspection must come first because it provides initial visual clues about distension, asymmetry, visible masses, skin changes (including "seatbelt sign" in trauma), lacerations, abrasions, and abdominal movement without disturbing the abdominal contents 2, 1
Auscultation is performed second, before any manipulation of the abdomen, because percussion and palpation can artificially alter bowel sounds, making subsequent auscultation unreliable 1
Percussion follows auscultation to detect areas of tenderness, dullness suggesting masses, shifting dullness indicating fluid or blood, organ enlargement, and free air in the peritoneum 2, 1, 3
Palpation is performed last because it is the most invasive component and can alter findings if done earlier; begin with light palpation to identify tender areas before proceeding to deep palpation 2, 1
Key Technical Points
Auscultation Technique
- Use the diaphragm of the stethoscope to listen for bowel sounds, bruits, and friction rubs 1
- Normal bowel sounds occur at a rate of 5-35 per minute 1
- Abdominal murmurs may suggest renovascular hypertension 1
Percussion Technique
- Approximately 1,500 mL of fluid must be present before flank dullness becomes detectable 1
- Shifting dullness has 83% sensitivity and 56% specificity for detecting ascites 1
Palpation Technique
- Always begin with light palpation before deep palpation 1
- Palpation helps identify enlarged kidneys, hepatomegaly, splenomegaly, and areas of tenderness 2, 1
- Significant abdominal tenderness and involuntary guarding are signs of peritonitis suggesting leakage of intestinal contents 2
Common Pitfalls to Avoid
- Never palpate before auscultating, as this alters bowel sounds and compromises diagnostic accuracy 1
- Failing to warm hands and stethoscope before patient contact causes discomfort and muscle guarding 1
- Palpating tender areas first increases patient discomfort and limits subsequent examination 1
- Rushing through inspection limits valuable initial information 1
- Applying excessive pressure during palpation before establishing areas of tenderness causes patient discomfort and limits the examination 1