Abdominal Assessment & Bowel Sounds

Physical Exam Techniques

• Percussion: Tapping to assess the density of underlying structures
• Auscultation: Listening to sounds arising from the body
• Inspection: Observing visually
• Palpation: Feeling areas of the body with the hands

Abdominal Regions

• Epigastric: Upper central abdominal area
• Umbilical: Area around the umbilicus
• Suprapubic/hypogastric: Lower central abdominal area just above the pubic area

Abdominal Quadrants

• RUQ: Right upper quadrant
• LUQ: Left upper quadrant
• RLQ: Right lower quadrant
• LLQ: Left lower quadrant

Abdomen: Inspection

• Inspect skin, umbilicus, and abdominal contour
• Note surgical scars, spider angiomas, striae (discolored stripes of skin), and distention (buildup of fluid or gas)

Abdomen: Auscultation of Bowel Sounds (BS)

• Auscultate all four quadrants just above the umbilicus
• Normal: hearing bowel sounds every 10 seconds (NABS)
• Abnormal: hyperactive or hypoactive bowel sounds

Abdomen: Abnormal Bowel Sounds

• Hypoactive: constipation (e.g., hypothyroidism, IBS, drug-induced causes, opioids, iron supplements)
• Hyperactive: diarrhea (e.g., diarrhea-inducing diseases, C. diff infection, IBS, drug-induced causes, stimulant laxatives, antibiotics)

Abdomen: Percussion

• Percuss all four quadrants
• Normal: tympanic note (high-pitched, drum-like sound) from air-filled loops of bowel
• Abnormal: shifting dullness (associated with ascites), quality should change from resonant to dull to tympanic

Abdomen: Percussion - Liver Span

• To assess: percuss down the right midclavicular line, begin above the rib margin, and end below the rib margin
• Normal span: ~10 cm (range: 6-12 cm)
• Abnormal: hepatomegaly (enlarged liver) – causes include hepatitis and cirrhosis

Abdomen: Palpation

• Light palpation: use pads of fingertips to apply light pressure in all four quadrants; note any tenderness or rigidity
• Deep palpation: use significant downward pressure with both hands in all four quadrants; note tender areas, masses, and needed structures (liver's edge, enlarged spleen, etc.)
• Normal: NTND (no tenderness, no dullness)
• Abnormal: suprapubic region tenderness (commonly associated with urinary tract infection (UTI), kidney stones), rebound tenderness (common cause - peritonitis)

Abdomen: Fluid Wave Test

• Press one hand on the right side of the abdomen, sharply tap the left wall of the abdomen with the other hand.
• Abnormal: (+) fluid wave (diagnostic of ascites)

Genitourinary Exam

• Inspection and palpation techniques are used
• Exam is not performed unless abnormalities are detected or the patient has GU complaints, or the patient is seen by a specialist (e.g. obstetrician, gynecologist, urologist , gastroenterologist)

Genitourinary: Inspection (External)

• Inspect sacrococcygeal and perianal areas, external genitalia for lumps, ulcerations, rashes, swelling, external hemorrhoids, and excoriations
• Inspect for discharge color/odor

Genitourinary: Abnormal Findings - Lesions

• Chancre: found on skin/mucous membrane of genitalia, commonly caused by Treponema pallidum (syphilis)
• Vesicle: small, circumscribed, elevated lesion containing serous fluid; commonly caused by herpes simplex virus (HSV)

Genitourinary: Abnormal Findings - Discharge

• Purulent urethral or rectal discharge: common cause - STI (e.g., Neisseria gonorrhoeae, Chlamydia trachomatis)
• Bright red blood per rectum (BRBPR): common causes - hemorrhoids, Crohn's disease, GI bleed
• Vaginal discharge: normal - clear/white, odorless. Abnormal - thick white “cheesy”, odorless (suggests yeast infection), gray/yellow-green, malodorous (suggests protozoal infection).

Genitourinary: Inspection (Internal)

• Inspect vaginal wall/cervix for color and lesions
• Normal cervix - smooth, pink; if intrauterine device (IUD), visible strings
• Abnormality - cervical petechiae (“strawberry cervix”) from microscopic hemorrhages of the cervix caused by trichomoniasis
• Cervical cells collected for cytologic evaluation (Pap test)

Genitourinary Exam: Palpation (Internal)

• Palpate cervix, uterus, and ovaries for size, shape, consistency, masses, tenderness, mobility
• Technique: “bimanual exam”
• Normal uterus - firm, smooth, freely movable, “pear shaped”
• Normal ovaries - slightly tender, very mobile, “almond shaped”
• Abnormal: cervical or uterine inflammation, pelvic inflammatory disease (PID), caused by STI.

Genitourinary Exam: Palpation (External)

• Palpate penis for indurations; scrotal structures (testis and epididymis) for size, shape, tenderness
• Abnormality: epididymitis - inflammation of the epididymis (caused by STI)
• Palpate inguinal and femoral areas for any indication of hernia.

Genitourinary Exam: Palpation (External)

• Palpate prostate for size & tenderness; palpate anus & rectal wall for tone & tenderness.
• Abnormality: prostatitis (painful swelling/inflammation of the prostate caused by STI or UTI)
• Abnormal: prostatic hypertrophy (associated with benign prostatic hypertrophy (BPH).

Musculoskeletal (MSK) System

• Assessed via inspection and palpation
• Areas examined: shoulders, elbows, wrists/hands, spine, hips, knees, and feet

Musculoskeletal: Inspection

• Inspect: symmetry, proportion, and muscular development, curvature of spine, gait, stance, movement, grasp.
• Abnormal: shuffling gait (Parkinson's Disease), muscle atrophy (immobilized/paralyzed limbs, elderly), scoliosis (lateral curvature spine), kyphosis (convex backward curvautre of spine), lordosis (accentuated curvature of spine).

Musculoskeletal: Palpation

• Palpate large and small joints for any tenderness, warmth, and crepitations, deformities
• Assess strength and range of motion (ROM) via flexion and extension.
• Abnormal: grip strength (associated with osteoarthritis and carpel tunnel syndrome), decreased joint ROM (associated with arthritis, tissue inflammation around joint), increased joint ROM (indicates joint instability or increased mobility).

Neuro Exam

• Assesses mental status, cranial nerve function, sensory & motor function, cerebellar function, and reflexes.
• Standard IPPA techniques are not used.
• Usually performed only if abnormalities are detected.

Neuro: Mental Status (MS)

• Determine if the patient's affect is appropriate
• Abnormalities: flat (severe reduction emotional expressiveness), labile (emotional instability/mood swings)
• Observe patient's speech throughout exam.
• Abnormalities: dysphasia and aphasia

Neuro: Mental Status (MS)

• Patient's level of consciousness; Awake, alert; confused, unresponsive
• Orientation to person, place, and time.
• Normal: A&Ox3 (alert & oriented to person, place, and time)

Neuro: Sensory Function Exam

• Evaluate patient’s ability to detect stimuli (pain, light touch, and vibratory sensations).
• Sensory function techniques: ask patient to close eyes, start distally and work proximally comparing left and right sides of body, ask patient to identify when and where touched using light touch, pain, and vibration.

Neuro: Sensory Function - Monofilament Foot Exam

• Assesses sensory function in feet, conducted in patients with diabetes and those on neurotoxic drugs
• Techniques: Inspect feet for sores, ulcers, and lesions, Direct the patient to close eyes and say “yes” when they feel monofilament, Touch monofilament to toes, plantar surfaces (apply pressure until it bends while holding for 1.5 seconds).
• Normal; (+) sensation at all locations; Abnormal: (-) sensation—denoted with (-) on diagram (loss of sensation).

Neuro: Sensory Function Abnormalities

• Hypoesthesia: loss of sensation
• Parasthesia: abnormal sensation (e.g., numbness, tingling, pricking, and burning)
• Neuropathy: nerve dysfunction, causes include diabetes, vitamin B12 deficiency, drug induced, Varicella zoster virus (shingles).

Neuro: Motor Function

• Observe involuntary movement - Abnormalities include: Asterixis (“liver flap”), dystonia, drug induced, resting tremor, intention tremor
• Assess muscle tone - resistance to passive stretch (flexion, extension, abduction, and adduction) - Abnormalities include; Rigid tone (Parkinson’s disease), flaccid tone (comatose patients)
• Assess muscle strength - instruct patient to push and pull against resistance - Normal finding: Muscle strength 5+; Abnormal findings: <5 (found in stroke, multiple sclerosis, hemi-, para-, or other conditions)

Neuro: Reflexes

• Includes biceps, triceps, brachioradialis, patellar, and Achilles reflexes
• Strike the tendon briskly with a reflex hammer and rate reflexes.
• Normal: DTR = 2+; Biceps reflex = 2+
• Abnormal: Hyporeflexia (0, 1+), Hyperreflexia (3+, 4+) , plantar reflex (stroke sole of foot from heel to ball using reflex hammer;normal finding is - in adults; Abnormal is + in adults causes include stroke, and multiple sclerosis.

Validated Tools - Cognitive Screening & Stroke (FYI)

• Mini-Cog (Memory Impairment Screen)
• MMSE (Mini Mental Status Exam)
• MoCA (Montreal Cognitive Assessment)
• NIH Stroke Scale: used to assess individuals with suspected stroke.

Test your knowledge of abdominal assessment techniques like auscultation, percussion, and palpation, focusing on the interpretation of bowel sounds, liver size, and causes of abdominal distention. This also covers conditions like cirrhosis and hypothyroidism.