Physical Examination of Abdomen

• The abdomen should be examined with the patient supine
• Rectal examination should be considered depending on the presentation
• The genitourinary examination should be considered depending on the presentation

Inspection

• General
  • How does the patient look?
  • Do they look sick?
• Skin
  • Color: erythema, ecchymosis, white, black
  • Trophic changes (altered hair growth, sweat production)
  • Scars
  • Cyanosis
• Swelling
• Muscle tone: atrophy, hypertrophy
• Deformity: asymmetry, rotation, amputation
• Areas of interest
  • Presence of surgical scars
  • Obesity of abdomen
  • Distension
  • Masses or bulges
  • Grey Turner sign: ecchymosis of the flank and groin
  • Cullen’s sign: periumbilical ecchymosis
  • Pink or purple striae
  • Caput Medusa: distended veins flowing away from the umbilicus
  • Ascites
  • Swollen lymph nodes
• Also look for
  • Pallor (conjunctival, mucosal)
  • Jaundice or scleral icterus
  • Petechiae

Auscultation

• Normal: low pitched, gurgling
  • Normally heard every 5-10 seconds
• Hyperactive
• Hypoactive
• Absent
• Bruit

Palpation

• General
  • The patient should be relaxed
  • Start with light palpation before deep palpation
  • Pressure should be slow, steady
  • Save self-reported area of pain for last
  • May require “distraction” by examiner
• Palpate by region/ area
  • Right upper quadrant
  • Right flank
  • Right lower quadrant
  • Epigastric
  • Periumbilical
  • Suprapubic
  • Left upper quadrant
  • Left flank
  • Left lower quadrant
• Potential Findings
  • Focal tenderness
  • Nonfocal or diffuse tenderness
  • Organomegaly (spleen, liver)
  • Masses
  • Rebound tenderness
  • Guarding (voluntary or involuntary)
  • Crepitus
  • Pulsatile mass
  • Hernia
• Additional pearls
  • Asking the patient to cough can increase intra-abdominal pressure and increase the protrusion of mass

Percussion

• General
  • Can be performed “separately” or as part of a palpation exam
  • Tympany: heard over air-filled viscera
  • Dull: heard over solid organs
• Define borders of liver, spleen
  • The note will change from tympanitic to dull
• Costovertebral angle
• Check for ascites

Rectal

• Externally inspect for
  • External blood
  • Fissure
  • Fistula
  • External hemorrhoids
• Palpation (digital rectal exam)
  • Use a lubricated gloved finger
  • Slide slowly to, gently to dilate the sphincter
  • Palpate for hemorrhoids, foreign body
  • Presence or absence of stool in the rectal vault
• The prostate can be examined if clinically appropriate
  • After exam
  • Examine finger for any signs of blood or melena in stool
  • Consider the guaiac test as clinically appropriate

Special Tests

• Appendicitis
  • McBurney’s point: tenderness ⅓ of the distance from ASIS to the umbilicus
  • Rovsing’s sign: deep palpation of the left lower quadrant causing pain in the right lower quadrant
  • Psoas sign; activation of right psoas muscle with hip flexion recreating the pain
  • Obturator sign: Flexing, internally rotating hip and knee causing increased pain

Other tests and special maneuvers

• Examination of pelvic lymph nodes
• Digital rectal exam only if clinically indicated.
• Pelvic examination only if clinically indicated.

Special maneuvers may also be performed, to elicit signs of specific diseases. These include

• Inflamed gallbladder: Murphy’s sign
  • During palpation beneath the bottom edge of the right rib cage, the patient experiences pain upon inspiration.
• Appendicitis or peritonitis:
  • Psoas sign – pain with extension of the hip and tensing of the psoas muscle
  • Obturator sign – pain when tensing the obturator muscle
  • Rovsing’s sign – pain in the right lower abdominal quadrant on palpation of the left side of the abdomen
  • McBurney’s sign – deep tenderness at McBurney’s point
  • Carnett’s sign – pain when tensing the abdominal wall muscles
  • Patafio’s sign – pain when the patient is asked to cough whilst tensing the psoas muscle
  • Cough test – pain when the patient is asked to cough
  • Valsalva maneuver – pain when the patient tries to forcefully exhale while closing their mouth and pinching their nose.
• Suspected Pyelonephritis: Murphy’s punch sign
• Hepatomegaly: Liver scratch test
• Rosenbach’s sign – Absence of abdominal reflex on one side of the abdomen in cerebral hemiplegia.
• Courvoisier’s sign – palpable distended gallbladder in jaundiced patients due to malignancy or obstruction
• Boas’s sign – Increased cutaneous sensitivity to the left of the 12th thoracic vertebrae in cholelithiasis.
• Krymov’s sign
• Berthier-Michelson’s sign
• Blumberg sign
• Shchetkin’s sign
• Aaron’s sign
• Volkovich sign
• Ten Horn’s sign
• Baldwin’s sign
• Rosenstein’s sign
• Fothergill’s sign
• Ascites: bulging flanks, fluid wave test, shifting dullness