Abdominal Exam

Auscultation

1. Listen to all 4 quadrants (diaphragm)
   • Normal bowel sounds: Gurgling, clicking, rumbling, and growling
   • Abnormal bowel sounds
     • High pitched, increased, or absent
     • Epigastric bruits: Renal artery stenosis or renovascular hypertension
     • Arterial bruits: Can indicate occlusions
     • Hepatic bruits: Can indicate liver cancer or cirrhosis
     • Venus hum: Can indicate liver cirrhosis
     • Friction rubs: Inflammation of peritoneal surface of organ (such as from liver cancer, splenic infarct, chlamydial or gonococcal perihepatitis)

Percussion

Tympanic sounds: Drum-like, typically heard over empty, gas filled spaces like the abdomen
Resonant sounds: Low-pitched and hollow, heard in lungs or chest cavity
Dull sounds: Heard over denser spaces (like those with organs or fluids)

1. Percuss all 4 quadrants (should sound tympanic)
2. Percuss the stomach, pressing down from left midclavicular from costal margin to bottom of LLQ, Listen for gastric bubble.
3. Percuss the liver
   1. Start at right midclavicular, below umbilicus. Move upward and note where the sound changes from tympanic to dull. Note this point.
   2. Start at right midclavicular, near 4th rib. Move downward and note where the sound changes from resonant to dull. Note this point.
   3. Measure between two points. Normal distance is 6-12 cm. (FYI, this is a poor test)
      
4. Percuss the spleen
   1. Start at left midclavicular near rib 6. Move laterally to left anterior axillary line.
   2. Start at the left anterior axillar line at the iliac crest. Move upward to the lowest intercostal space.
   3. When at lowest intercostal space, perform splenic percussion sign (normal tidal breathing and with a deep inhale with hold)
      

Palpation

1. Palpate all 4 quadrants, superficial then deep.
   • Use your dominant hand on top of non-dominant hand
   • Superficial detects tenderness, masses, protrusions. Deep finds the outlines of the organs.
2. Palpate the liver
   1. Use identified lower point
   2. Ask patient to inhale and feel for border as it approaches your fingers
   3. Ask patient to exhale and press deep + up (cephalically)
3. Palpate the spleen (will not feel anything on healthy patient)
   1. Place left hand under the back of the patient's left rib cage then lift/prop up (to make spleen sit more anteriorly)
   2. Place right hand near umbilicus and continue diagonally up the left costal margin
   3. Ask patient to inhale and feel for spleen
   4. Ask patient to exhale and press deeply and diagonally (towards costal margin)