Abdomen

Equipment

• Stethoscope

• Centimeter ruler and measuring tape

• Marking pen

Examination

Have patient in the supine position to start the examination. Approach the patient from the right side.

Technique Findings
Inspect abdomen
EXPECTED: Usual color variations, such as paleness or tanning lines. Fine venous network (venous return toward head above umbilicus, toward feet below umbilicus).
UNEXPECTED: Generalized color changes, such as jaundice or cyanosis. Glistening, taut appearance. Bluish periumbilical discoloration, bruises, other localized discoloration. Striae, lesions or nodules, a pearl-like enlarged umbilical node, scars.
EXPECTED: Flat, rounded, or scaphoid. Contralateral areas symmetric. Maximum height of convexity at umbilicus. Abdomen remains smooth and symmetric while patient holds breath.
  UNEXPECTED: Umbilicus displaced upward, downward, or laterally or is inflamed, swollen, or bulging. Any distention (symmetric or asymmetric), bulges, or masses while breathing comfortably or holding breath.
EXPECTED: Smooth, even motion with respiration. Female patients mostly costal movement; male patients mostly abdominal. Pulsations often visible in upper midline in thin adults.
UNEXPECTED: Limited motion with respiration in male adults. Rippling movement (peristalsis) or marked pulsations.

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Anatomic Correlates of the Four Quadrants of the Abdomen
Inspect abdominal muscles as patient raises head
  EXPECTED: No masses or protrusions.
UNEXPECTED: Masses, protrusion of the umbilicus and other hernia signs, or separation of rectus abdominis.
Auscultate with stethoscope diaphragm
EXPECTED: 5-35 irregular clicks and gurgles per minute. Borborygmi, or increased sounds, may be because of hunger.
UNEXPECTED: Increased sounds unrelated to hunger and high-pitched tinkling sounds may be caused by early intestinal obstruction; decreased or absent sounds after 5 min of listening may be associated with abdominal pain and rigidity.
EXPECTED: Silent.
UNEXPECTED: Friction rubs (high-pitched grating sound in association with respiration).
Auscultate with stethoscope bell
EXPECTED: No bruits (harsh or musical sound indicating blood flow turbulence), venous hum (soft, low-pitched, and continuous sound), or friction rubs.
UNEXPECTED: Bruits in aortic, renal, iliac, or femoral arteries.
EXPECTED: No venous hum.
UNEXPECTED: Venous hum.
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(From Wilson and Giddens, 2009.)

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Technique Findings
Percuss abdomen
Note: Percussion can be done independently or concurrently with palpation.
EXPECTED: Tympany predominant. Dullness over organs and solid masses. Dullness in suprapubic area from distended bladder. See table on p. 136 for percussion notes.
UNEXPECTED: Dullness predominant.

• Liver span

To determine lower liver border, percuss upward at right midclavicular line, as shown in figure on p. 138, and mark with a pen where tympany changes to dullness. To determine upper liver border, percuss downward at right midclavicular line from an area of lung resonance, and mark change to dullness. Measure the distance between marks to estimate vertical span.

 EXPECTED: Lower border usually begins at or slightly below costal margin. Upper border usually begins at fifth to seventh intercostal space. Span generally ranges from 6 to 12 cm in adults.
UNEXPECTED: Lower liver border >2-3 cm below costal margin. Upper liver border above the fifth or below the seventh intercostal space. Span <6 cm or >12 cm.
EXPECTED: Small area of dullness from sixth to tenth rib. Tympany before and after deep breath.
UNEXPECTED: Large area of dullness (check for full stomach or feces-filled intestine). Tone change from tympany to dullness with inspiration.
EXPECTED: Tympany of gastric air bubble (lower than intestine tympany).
UNEXPECTED: Dullness.
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Lightly palpate abdomen
Stand at patient’s right side. Systematically palpate all quadrants, avoiding areas previously identified as problem spots. With palmar surface of fingers, depress abdominal wall up to 1 cm with light, even circular motion. EXPECTED: Abdomen smooth with consistent softness. Possible tension from palpating too deeply, cold hands, or ticklishness.
UNEXPECTED: Muscular tension or resistance, tenderness, or masses. If resistance is present, place pillow under patient’s knees and ask patient to breathe slowly through mouth. Feel for relaxation of rectus abdominis muscles on expiration. Continuing tension signals involuntary response to localized or generalized rigidity.
Palpate abdomen with moderate pressure
Using same hand position as above, palpate all quadrants again, this time with moderate pressure. EXPECTED: Soft, nontender
UNEXPECTED: Tenderness.
Deeply palpate abdomen
With same hand position as above, repeat palpation in all quadrants or regions, pressing deeply and evenly into abdominal wall. Move fingers back and forth over abdominal contents. Use bimanual technique—exerting pressure with top hand and concentrating on sensation with bottom hand, as shown in figure below—if obesity or muscular resistance makes deep palpation difficult. To help determine whether masses are superficial or intraabdominal, have patient lift head from examining table to contract abdominal muscles and obscure intraabdominal masses.
image		 EXPECTED: Possible sensation of abdominal wall sliding back and forth. Possible awareness of borders of rectus abdominis muscles, aorta, and portions of colon. Possible tenderness over cecum, sigmoid colon, and aorta and in midline near xiphoid process.
UNEXPECTED: Bulges, masses, tenderness unrelated to deep palpation of cecum, sigmoid colon, aorta, xiphoid process. Note location, size, shape, consistency, tenderness, pulsation, mobility, movement (with respiration) of any masses.
EXPECTED: Umbilical ring circular and free of irregularities. Umbilicus either slightly inverted or everted.
UNEXPECTED: Bulges, nodules, granulation. Protruding umbilicus.
EXPECTED: Usually liver is not palpable. If felt, liver edge should be firm, smooth, even.
UNEXPECTED: Tenderness, nodules, or irregularity.
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EXPECTED: Gallbladder not palpable.
UNEXPECTED: Palpable, tender. If tender (possible cholecystitis), palpate deeply during inspiration and observe for pain (Murphy sign).
EXPECTED: Spleen usually not palpable by either method.
UNEXPECTED: Palpable spleen.
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EXPECTED: Left kidney usually not palpable.
UNEXPECTED: Tenderness.
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EXPECTED: If palpable, right kidney should be smooth and firm with rounded edges.
UNEXPECTED: Tenderness.
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EXPECTED: If prominent, pulsation should be anterior in direction.
UNEXPECTED: Prominent lateral pulsation (suggests aortic aneurysm).
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EXPECTED: Ordinarily not palpable unless distended with urine. If distended, bladder should be smooth, round, and tense, and on percussion will elicit lower note than surrounding air-filled intestines.
UNEXPECTED: Palpable when not distended with urine.
With patient sitting, percuss CVAs
Stand behind patient. Right side: Place left hand over right CVA and strike with ulnar surface of right fist. Left side: Repeat with hands reversed. EXPECTED: No tenderness.
UNEXPECTED: Kidney tenderness or pain.
Pain assessment
Keep eyes on patient’s face while examining abdomen. To help characterize pain, have patient cough, take a deep breath, jump, or walk. Ask whether patient is hungry. UNEXPECTED: Unwillingness to move, nausea, vomiting, areas of localized tenderness. Lack of hunger. See box and table on p. 144.
Iliopsoas muscle test
Use test for suspected appendicitis. With patient supine, place hand over right lower thigh. Ask patient to raise leg, flexing at hip, while you push downward. UNEXPECTED: Right lower quadrant (RLQ) pain.
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Obturator muscle test
Use test for suspected ruptured appendix or pelvic abscess. With patient supine, ask patient to flex right leg at hip and bend knee to 90 degrees. Hold leg just above knee, grasp ankle, and rotate leg laterally and medially, as shown in figure. UNEXPECTED: Pain in right hypogastric region.
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(From Wilson and Giddens, 2009.)

Some Causes of Pain Perceived in Anatomic Regions

AIDS TO DIFFERENTIAL DIAGNOSIS

Subjective Data Objective Data
Hiatal Hernia with Esophagitis
Epigastric pain and/or heartburn that worsens with lying down and is relieved by sitting up or antacids; water brash (mouth fills with fluid); dysphagia; sudden onset of vomiting, pain, complete dysphagia are symptoms of hernia incarceration. With severe disease, may have erythema of the posterior pharynx and edematous vocal cords.
Gastroesophageal Reflux Disease
Heartburn or acid indigestion (burning chest pain, located behind breastbone that moves up toward the neck and throat); sour taste of acid in the back of the throat or hoarseness; symptoms in infants and children include back arching or fussiness with feeding, regurgitation, and vomiting; can precipitate acute asthma exacerbation, can cause respiratory problems from aspiration, and can lead to esophageal bleeding. With severe disease, may have erythema of the posterior pharynx and edematous vocal cords; when frequent emesis occurs, may cause failure to thrive in an infant.
Duodenal Ulcer
Localized epigastric pain that occurs when the stomach is empty and is relieved with food or antacids; with upper gastrointestinal bleeding, may have hematemesis, melena, dizziness, syncope. Anterior wall ulcers may produce tenderness on palpation of the abdomen; with significant upper gastrointestinal bleeding, may have decreased blood pressure, increased pulse rate, and decreased hematocrit level; signs of an acute abdomen could indicate perforation of duodenum, a life-threatening event.
Acute Diarrhea
Abrupt onset, lasts <2 weeks; abdominal pain, diarrhea, nausea, vomiting, fever, tenesmus (feeling of incomplete defecation); if symptoms occur in two or more persons after ingestion of the same food, suspect food poisoning. Diffuse abdominal tenderness; can mimic peritoneal inflammation with RLQ pain or guarding; when severe, may develop moderate to severe dehydration (decreased blood pressure, increased heart rate).
Crohn’s Disease
Chronic diarrhea (can be bloody) with malabsorption, cramping characterized by unpredictable flares and remissions. Abdominal mass may be palpated from thickened or inflamed bowel; perianal skin tags, fistulae, and abscess formation; extraintestinal findings include arthritis of large joints, erythema nodosum, pyoderma gangrenosum.
Ulcerative Colitis
Bloody, frequent (up to 20-30 stools/day), watery diarrhea; mild to severe symptoms based on degree of colon involvement; weight loss, fatigue, general debilitation. Generally do not have fistulae or perianal disease; cholestatic pattern of elevated transaminases suggests sclerosing cholangitis.
Irritable Bowel Syndrome
Cluster of symptoms consisting of abdominal pain, bloating, constipation, and diarrhea; some patients have alternating diarrhea and constipation; mucus may be present around or within the stool. Generally unremarkable examination.
Colon Cancer
May have abdominal pain, gross blood in stool, but more often presents with occult blood in stool on fecal occult blood test; may have change in frequency or character of stool. With progressive disease, may have palpable mass in right (RLQ) or left lower quadrant (LLQ); rectal mass may be palpable on digital rectal examination.
Hepatitis
Some asymptomatic; others experience jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, fatigue. Abnormal liver function tests; jaundice; hepatomegaly.
Cirrhosis
Some asymptomatic; others experience jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, fatigue; may report prominent abdominal vasculature, cutaneous spider angiomas, hematemesis, abdominal fullness. Abnormal liver function tests; jaundice; initially with firm, nontender enlarged liver; in severe disease, liver size decreases, portal hypertension and esophageal varices may develop, and muscle wasting and nutritional deficiencies may occur.
Cholecystitis
Acute: Right upper quadrant (RUQ) pain with radiation around midtorso to right scapular region; pain is abrupt and severe, lasting 2-4 hours; may have fever, jaundice, anorexia. Chronic: Repeated acute attacks; fat intolerance, flatulence, nausea, anorexia, nonspecific abdominal pain. Marked tenderness in the RUQ or epigastrium; involuntary guarding or rebound tenderness; some with full palpable gallbladder in RUQ.
Chronic Pancreatitis
Unremitting abdominal pain, weight loss, steatorrhea. Diffuse abdominal tenderness to palpation; involuntary guarding and abdominal distention can occur; elevated pancreatic enzymes (amylase and lipase); may develop pseudocyst formation; with advanced disease, may show subcutaneous fat and temporal wasting from malnutrition.
Pyelonephritis
Flank pain, dysuria, fever; may have rigors, urinary frequency, urgency, and hematuria. Ill appearing with CVA tenderness; pyuria and bacteria.
Renal Calculi
Fever, dysuria, hematuria; severe cramping and flank pain with nausea and vomiting; as the stone passes, pain typically moves from flank to groin to scrotal or labial area. Ill appearing with severe cramping pain; may have CVA tenderness or abdominal tenderness on palpation; microscopic hematuria.
Appendicitis
Initially periumbilical or epigastric pain; colicky; later becomes localized to RLQ; anorexia, nausea, or vomiting after onset of pain; low-grade fever. Guarding, tenderness, positive iliopsoas and/or obturator signs, RLQ pain on palpation (McBurney’s sign).

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Conditions That Produce Acute Abdominal Pain

Condition Usual Pain Characteristics Possible Associated Findings
Appendicitis Initially periumbilical or epigastric; colicky; later becomes localized to RLQ, often at McBurney’s point Guarding, tenderness; positive iliopsoas and positive obturator tests, RLQ skin hyperesthesia; anorexia, nausea, or vomiting after onset of pain; low-grade fever; positive Aaron, Rovsing, Markle, and McBurney signs∗
Peritonitis Onset sudden or gradual; pain generalized or localized, dull or severe and unrelenting; guarding; pain on deep inspiration Shallow respiration; positive Blumberg, Markle, and Ballance signs; reduced bowel sounds, nausea and vomiting; positive obturator and iliopsoas tests
Cholecystitis Severe, unrelenting RUQ or epigastric pain; may be referred to right subscapular area RUQ tenderness and rigidity, positive Murphy sign, palpable gallbladder, anorexia, vomiting, fever, possible jaundice
Pancreatitis Dramatic, sudden, excruciating left upper quadrant (LUQ), epigastric, or umbilical pain; may be present in one or both flanks; may be referred to left shoulder Epigastric tenderness, vomiting, fever, shock; positive Grey Turner sign; positive Cullen sign; both signs may occur 2-3 days after onset
Salpingitis Lower quadrant, worse on left Nausea, vomiting, fever, suprapubic tenderness, rigid abdomen, pain on pelvic examination
Pelvic inflammatory disease Lower quadrant, increases with activity Tender adnexa and cervix, cervical discharge, dyspareunia
Diverticulitis Epigastric, radiating down left side of abdomen especially after eating; may be referred to back Flatulence, borborygmi, diarrhea, dysuria, tenderness on palpation
Perforated gastric or duodenal ulcer Abrupt RUQ; may be referred to shoulders Abdominal free air and distention with increased resonance over liver; tenderness in epigastrium or RUQ; rigid abdominal wall, rebound tenderness
Intestinal obstruction Abrupt, severe, spasmodic; referred to epigastrium, umbilicus Distention, minimal rebound tenderness, vomiting, localized tenderness, visible peristalsis; bowel sounds absent (with paralytic obstruction) or hyperactive high-pitched (with mechanical obstruction)
Volvulus Referred to hypogastrium and umbilicus Distention, nausea, vomiting, guarding; sigmoid loop volvulus may be palpable
Leaking abdominal aneurysm Steady throbbing midline over aneurysm; may penetrate to back, flank Nausea, vomiting, abdominal mass, bruit
Biliary stones, colic Episodic, severe, RUQ, or epigastrium lasting 15 min to several hours; may be referred to subscapular area, especially right RUQ tenderness, soft abdominal wall, anorexia, vomiting, jaundice, subnormal temperature
Renal calculi Intense; flank, extending to groin and genitals; may be episodic Fever, hematuria; positive Kehr sign
Ectopic pregnancy Lower quadrant; referred to shoulder; with rupture is agonizing Hypogastric tenderness, symptoms of pregnancy, spotting, irregular menses, soft abdominal wall, mass on bimanual pelvic examination; ruptured: shock, rigid abdominal wall, distention; positive Kehr, Cullen signs
Ruptured ovarian cyst Lower quadrant, steady, increases with cough or motion Vomiting, low-grade fever, anorexia, tenderness on pelvic examination
Splenic rupture Intense; LUQ, radiating to left shoulder; may worsen with foot of bed elevated Shock, pallor, lowered temperature

∗See table on pp. 148-149 for explanation of signs.

Sample Documentation

Subjective

A 44-year-old woman describes a burning sensation in epigastric area and chest. Occurs after eating, especially with spicy foods. Lasts 1 to 2 hours and is worse when lying down. Sometimes causes bitter taste in mouth. Also feels bloated. Antacids do not relieve symptoms. Denies nausea/vomiting/diarrhea. No cough or shortness of breath.