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Questions and Answers
What is the significance of palpating the liver edge during the examination?
What technique is recommended for performing deep palpation of the abdomen?
During abdominal palpation, which area should be assessed first for liver palpation?
What should a healthcare provider do if they identify a mass during deep palpation?
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Why is it important to monitor the patient's face during deep palpation?
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In which circumstance is the gallbladder typically palpable?
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What characteristic of the liver edge may suggest it is grossly enlarged?
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What should be done after palpating the liver edge and if it's not detectable?
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Which structures are typically found in the right upper quadrant (RUQ)?
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What is the primary reason a healthy adult's pancreas is not typically palpable?
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Which of the following statements about palpating organs is correct?
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What is the typical location of the spleen in relation to other organs?
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What is the angle formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae known as?
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Which quadrants of the abdomen contain the sigmoid colon?
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What does flexing the knees during an abdominal examination help to achieve?
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Where is a distended bladder typically palpable?
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When evaluating the abdomen, which order should the steps be performed?
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How much urine can the bladder typically accommodate before contraction is stimulated?
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What does a protuberant or distended abdomen indicate?
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What fact is true about the examination of the abdomen?
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Which condition is indicated by Cullen's and Grey Turner's signs?
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What does bulging flanks indicate in a patient?
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What abnormal sign indicates possible intestinal obstruction?
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Which of the following indicates the presence of portal hypertension?
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What could a purple discoloration of the abdominal skin indicate?
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Which of the following describes a potential cause of abdominal asymmetry?
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During an abdominal examination, what is the correct order for auscultation?
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What distinguishes normoactive bowel sounds from hyperactive sounds?
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Why should palpation be the last step in an abdominal physical exam?
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What is the correct order of examination techniques used for assessing the abdomen?
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During an abdominal examination, which of the following findings can be noted through inspection?
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What conclusion can be drawn if a patient presents with no signs of peripheral oedema during an abdominal examination?
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Which statement is true regarding the examination findings of a patient with no abdominal distension?
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What can be inferred from a regular pulse of 70 beats per minute during an examination?
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What does the absence of lymphadenopathy in the supraclavicular region suggest?
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What does normal bowel sounds during an abdominal examination indicate?
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Why is it important to thank and explain to the patient that the examination is finished?
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Study Notes
Abdominal Examination
- Before beginning abdominal palpation, warm your hands, have the patient empty their bladder, and ask them to point to any areas of tenderness.
- Lightly palpate each of the nine abdominal regions to assess for clinical signs suggestive of gastrointestinal pathology including:
- Tenderness
- Rigidity
- Masses
- Enlarged organs
- Rebound tenderness
- Guarding
- Deeply palpate each of the nine abdominal regions applying greater pressure to identify any deeper masses.
- If any masses are identified, assess the following characteristics:
- Location
- Size
- Shape
- Consistency
- Tenderness
- Pulsatility
- Mobility
- If any masses are identified, assess the following characteristics:
- Begin liver palpation in the right iliac fossa, starting at the edge of the superior iliac spine, using the flat edge of your hand (the radial side of your right index finger).
- Ask the patient to take a deep breath and palpate the abdomen as they begin to inhale. Feel for a step as the liver edge passes below your hand during inspiration.
- Repeat palpation, moving 1-2 cm superiorly from the right iliac fossa towards the right costal margin each time.
- Once you get close to the costal margin, the liver edge may become palpable in healthy individuals.
- If you are able to identify the liver edge, assess the following characteristics:
- Size
- Consistency
- Tenderness
- Smoothness
- Shape
- Causes of hepatomegaly include:
- Fatty liver disease
- Hepatitis
- Cirrhosis
- Liver cancer
- Congestive heart failure
- Polycythemia vera
- Lymphoma
- If any masses are identified, assess the following characteristics:
- Location
- Size
- Shape
- Consistency
- Tenderness
- Pulsatility
- Mobility
- In healthy individuals, the gallbladder is not usually palpable
- Explain to the patient that the examination is now finished and thank them for their time.
- Dispose of PPE appropriately and wash your hands.
- Summarise your findings.
- For completeness, consider performing further assessments and investigations, such as:
- Blood tests
- Imaging scans (including ultrasound, CT scan, or MRI)
- Endoscopy (such as an upper endoscopy or colonoscopy)
- Biopsy
- The correct sequence of techniques used during an examination of the abdomen is inspection, auscultation, percussion, and palpation.
- Inspection of the abdomen can reveal:
- Venous pattern
- Peristaltic waves
- Abdominal contour
- Right upper quadrant tenderness may indicate pathology in the gallbladder.
- A physical exam of the abdomen consists of:
- Inspection
- Auscultation
- Percussion
- Palpation
- The liver is soft and difficult to feel through the abdominal wall.
- The gallbladder rests on the inferior surface of the liver and more deeply lying duodenum.
- The right kidney may be felt in a thin person with abdominal muscles relaxed.
- The abdominal aorta often has a visible pulsation in the upper abdomen.
- The organs of the RUQ are:
- Liver
- Gallbladder
- Pylorus
- Duodenum
- Head of Pancreas
- Right adrenal gland
- Superior Aspect of Right Kidney
- Hepatic Flexure of ascending colon
- Portions of ascending and transverse colon
- The spleen is lateral to and behind the stomach just above the left kidney in the L MAL.
- Ribs 9-10-11 protect most of the spleen.
- The tip of the spleen may be palpable below the left costal margin in a small percentage of adults.
- The pancreas is not palpable in healthy adults.
- The organs of the LUQ are:
- Left lobe of the liver
- Spleen
- Stomach, body of pancreas
- Left adrenal gland and upper aspect of left kidney
- Splenic flexure of colon
- Portion of transverse and descending colon
- In the LLQ, you can often feel the firm narrow tubular sigmoid colon.
- The LLQ also contains portions of the transverse and descending colon. In the lower mid line are the bladder, the sacral promontory, the bony anterior edge of the S1 vertebra, and in women, the uterus and ovaries.
- The organs of the LLQ are:
- Lower lobe of left kidney
- Sigmoid colon
- Portion of descending colon
- Left Ureter (bladder if distended)
- Left overt and tube (uterus if enlarged)
- The RLQ contains the bowel loops, the appendix at the tail of the cecum near the junction of the small and large intestines.
- The organs of the RLQ are:
- Lower pole of right kidney
- Cecum and appendix
- Portion of ascending colon
- Right ovary and tube (uterus if enlarged)
- Right ureter (bladder if distended)
- A distended bladder may be palpable above the symphysis pubis.
- About 300 ml of urine can be accommodated before smooth muscle and detrusor muscle are stimulated to contract.
- The kidneys are not easy to palpate.
- The angle formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae is called the Costovertebral angle (CVA).
- The CVA is the area to test for kidney tenderness.
- Flexing the knees during an examination helps relax tension on the abdominal muscles.
- Positioning the patient supine with arms at sides exposes the entire abdomen from the xyphoid to the suprapubic area.
- You should stand on the patient's right side.
- The patient can assist in evaluation by pointing to any areas of tenderness.
- The orders of evaluation of the abdomen are, in order:
- Inspection
- Auscultation
- Percussion
- Palpation
- Peritonitis is an inflammation (irritation) of the peritoneum (the tissue that lines the wall of the abdomen and covers the abdominal organs.
- Patients with peritonitis usually lie still because movement leads to pain.
- Patients with obstructions of the colon, small intestine, and stones of the kidney and gall bladder "Constantly Move" in order to gain comfort.
- A flat contour abdomen indicates a healthy abdomen.
- A round contour abdomen indicates obesity.
- A protuberant or distended abdomen indicates prominent convexity of the abdomen due to excessive subcutaneous or visceral fat, poor muscle tone, or an increase in the contents of the abdomen.
- A scaphoid (hollowed) abdomen indicates malnutrition.
- Flanks that bulge indicate ascites.
- Local bulges in the abdomen may indicate a hernia.
- Visible masses in the abdomen may indicate lipomas or hernias.
- Asymmetry of the abdomen may indicate organomegaly or a tumor.
- Increased peristaltic waves indicate intestinal obstruction.
- A normal aortic pulsation may be visible in the epigastrium, but may be widened with an aneurysm.
- Enlarged veins may be caused by:
- Emaciation
- Portal hypertension
- Inferior Vena Cava Obstruction
- Emaciation is the loss of subcutaneous fat, and causes normal (invisible) veins to become prominent.
- Portal hypertension causes the umbilical vein to become an outflow tract of the portal system and forms collaterals with veins of the abdominal wall, creating a CAPUT MEDUSA. This is diagnostic of portal hypertension.
- Cullen’s and Grey Turner’s signs are bluish discoloration of the umbilicus and the flanks, respectively.
- Cullen’s and Grey Turner’s signs are indicative of intra-abdominal and retroperitoneal bleeding.
- Blood can reach these bruising sites (rashes, ecchymosis) through abnormalities to note on abdominal skin inspection
- Paleness of the abdominal skin (paler than general skin tone ) can be normal due to less exposure, but may also be seen with ascites along with a taut abdomen. Purple skin indicates possible trauma, and purple striae indicates Cushing's disease. Yellow skin indicates jaundice, and redness indicates inflammation.
- Ecchymosis of the abdominal wall may be a sign of intraperitoneal or retroperitoneal hemorrhage.
- Abnormalities to note on inspection of the umbilicus include color, location, contour; note any bulges or inflammation, an enlarged everted appearance may indicate an umbilical hernia.
- The contour of the abdomen can be described as flat, scaphoid (concave/hollowed), rounded, distended/protuberant, or obese.
- Possible causes of abdominal asymmetry include organ enlargement, large masses, hernia, diastasis recti, and bowel obstructions.
- Abdominal movements that may be visible on physical exam include abdominal respiratory movements, aortic pulsations, and peristaltic waves.
- Palpation may alter the characteristics of bowel sounds, which is the reason why it is important that palpation is the last part of the abdominal physical exam.
- The steps of abdominal auscultation are as follows:
- Start in the RLQ and proceed clockwise.
- Auscultate for bowel sounds in all 4 quadrants and note the intensity, pitch, character, and frequency.
- Listen over the liver and spleen for friction rubs.
- Auscultate for vascular sounds (e.g., bruits, venous hum) using the bell of the stethoscope.
- Normoactive bowel sounds are soft clicks and gurgles at a rate of 5 to 34 per minute. Borborygmus (growling or rumbling) is also considered normal.
- Hyperactive bowel sounds are >34/minute, and hypoactive bowel sounds are <5/minute.
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Description
This quiz covers essential techniques for conducting an abdominal examination, including methods of palpation to assess various clinical signs of gastrointestinal issues. You'll learn how to identify tenderness, rigidity, masses, and other key indicators of abdominal health. Test your knowledge on the proper steps for an effective examination.
