Abdominal examination

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By the Book

P46 of the clinical skills manual

The student shall be able to examine the abdomen with the patient relaxed lying comfortably in the supine position with the examiner on the patient's left or right side according to the following procedures:

  1. Inspect abdominal wall for abnormal contour, asymmetry, distention, scars, dilated veins, skin lesions, visibly enlarged organs, masses, pulsation, dilated loops of bowel and peristaltic waves, and for incisional hernia by asking patient to raise the head or to cough to increase intra-abdominal pressure.
  2. Palpate lightly with the palm and fingers of the hand the four quadrants of the abdomen for areas of discomfort or resistance of an underlying organ or mass.
  3. Palpate deeply by flexing the hand at the metatarsal phalangeal joint for tenderness, enlarged organs or masses, and when tenderness is found determine whether it is superficial or deep by palpation with the patient's head raised off the bed to tense the abdominal wall.
  4. Palpate with the hand outside the lateral margin of the right rectus muscle for the lower margin of the liver with the patient taking deep breaths; and when palpable, percuss the upper margin of the liver and then measure in centimetres the distance between the upper and lower margins in the mid clavicular line.
  5. Palpate lightly with the hand outside the lateral margins of the left rectus muscle for the lower margin of the spleen and if palpable measure distance below costal margin in an appropriate plane.
  6. Palpate the abdominal aorta for enlargement (increase in width).
  7. Palpate bimanually for the lower margins of the kidneys.
  8. Palpate the inguinal region for enlarged lymph nodes, masses and for the amplitude of the femoral pulses.
  9. Auscultate the abdomen. Listen for a bruit over the aorta and listen for presence/absence of bowel sounds (this is sometimes done before palpation).
  10. With the patient (male) either standing or lying flat, be able to inspect and palpate the scrotum and penis for ulceration, irregularities and masses.
  11. With the patient (male) standing and the examiner in front, test the inguinal canals for herniae.
  12. Understand the principles of the rectal exam. Students are referred to a teaching module in the Learning Resource Centre.
    • Inspect the anus and perianal area for excoriation, skin tags and external haemorrhoids.
    • Palpate the anal canal and rectum.
    • Palpate the prostate to estimate size, detect tenderness and determine whether the surface is smooth or irregular


  • trombi space - Space ??????????????
  • McBermy's point - a spot to look for appendix problems



  • Should be 12cm or so
  • According to Birmingham (quoted in Gray's Anatomy) the limits of the normal liver may be marked out on the surface of the body in the following manner. Take three points: (a) 1.25 cm. below the right nipple; (b) 1.25 cm. below the tip of the tenth rib; (c) 2.5 cm. below the left nipple. Join (a) and (c) by a line slightly convex upward; (a) and (b) by a line slightly convex lateralward; and (b) and (c) by a line slightly convex downward.


  • See 1225
  • about level of belly button
  • cannot be observed unless person is cadavericly thin


  • "Marge!!! It's uterus, not uteryou"


  • there's a lot of other stuff in there too

Lymph Glands


Bowel sounds are highly variable with people



  • Could be pleural, pericardial, or such.
  • means there is some problem with the lining (e.g., pericarditis, peritoneum, or pleura)
  • detected with auscultation

Splenic infarct

  • Whenever the spleen grows too large for the blood supply


  • Enlarged spleen


  • Increased fluid in the abdomen
  • On inspection, distention is observed
  • On palpation, midline is resonant but periphery isn't
    • then get patient to turn onto side and repeat. Midline should become dull now
  • Ascites can be identified in 2 ways:
    1. shifting dullness - palpation dullness moves depending on position of
    2. fluid wave (thrill) - (quickly) push on one end to produce a wave which could be detected on the other.

Paralytic Illius

  • occurs after surgery or any disturbance in the abdomen
  • distends if not treated
  • when auscultated, it is silent



  • Not tremendously rare
  • Put finger into belly button and get them to cough or breathe


  • A bulge occurs where the incision happened


  • more common in men than women
  • peek out in scrotum of men
  • with males, take finger (pinky) on scrotum and curve into inquinal canal
  • if there is an indirect inguinal hernia, you'll feel it hit your finger from the front (???? FACT CHECK)
  • if it is a direct inguinal hernia, you'll feel it hit your finger from behind


  • more common in women than men
  • less common than inguinal hernias

Diastasis recti

  • Defect in the midline such that when a person raises their head, everything bulges out at the midline


Castelle's Sign

  • Dullness on inspiration over spleen
  • When percussing
  • implies enlarged spleen


  • Always work from resonant to dull
  • Percuss around looking for unexpected dullness


  • Start from below the enlarged part
  • Assess regular vs irregular
  • Assess soft vs firm
  • Assess regular margin vs irregular margin
  • Can be used to identify margins of


  • put one hand into flank and another over area of interest
  • push up and feel for bump against hand
  • used to detect things that are retroperitoneal

If you can get above it, it's not a spleen If it moves vertically (instead of diagonally), it's not a spleen Enlarged spleen has a splenic notch If Trombi space is resonant, it's not a spleen

Murphy's Sign



1219 - Surface appearance 1224 1225 - kidneys