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StatPearls . Sweetheart Island (FL): StatPearls Publishing; 2021 Jan-.


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Introduction

Physical check plays a vital role in patient diagnosis and is crucial part of every clinical encounter of the patient through the physician. An abdominal examination can offer diagnostic clues concerning most gastrointestinal and genitourinary pathologies and also may likewise give insight regarding abnormalities the other body organ systems. A well-performed ab examination reduce the need for in-depth radiological investigations likewise plays crucial role in patient management.  


Function

The ab examination is performed v the patient lying supine. The examiner should start by giving their formal development and then strategy the patient and perform the examination from the right side the the patient. The initial procedures are explained as follows:


Wash hands thoroughly with soap and water. An alcohol-based sanitizer can also be used. The examiner demands to ensure the their hands room dry and also warm before beginning the examination.
Identify the patient.
Briefly define the reason for and the measures of the examination and take consent indigenous the patient.
Inquire if the patience has any pain.
Position the patient. The patient is initially positioned at 45 levels for comfort, but a supine position is important to palpate the abdomen. Keeping a pillow under the patient’s head or knees can be considered.
The best exposure is from the nipples to the knees, but this is occasionally not virtually possible. Throughout most clinical examinations, the exposure is indigenous the nipples to the reduced abdomen.

General Inspection

Begin with the general inspection that the patient and also then continue to the abdominal area. This should be performed in ~ the foot end of the bed. The general inspection can offer multiple clues about the patient"s diagnosis; because that example, yellowish discoloration that the skin (jaundice) indicates a feasible hepatic abnormality. The is necessary to note any medical equipment for monitoring and/or therapy attached come the patient or existing in the bed space. This may encompass catheters, pulse oximeter, oxygen mask and also tubing, nasogastric tube, main lines, and total parenteral nutrition lines.

Examination that the Hands and Arms

The hands should be examined for the existence of pallor and jaundice. The outstretched hands room observed because that the existence of tremors. A flapping tremor (asterixis) shows hepatic encephalopathy and also may be present in cirrhosis.<1><2> A non-specific tremor may likewise indicate alcohol withdrawal. The radial pulse should be examined, and the blood pressure should be recorded. The hands and arms must be check for proof of intravenous drug use, which might be current as injection website marks. The visibility of one arteriovenous fistula shows renal replacement therapy and should be inspected and also palpated.

Examination of the Face and also Neck

The check should start by asking the patient to look right ahead. The eyes need to be examined for scleral icterus and also conjunctival pallor. Extr findings might be present; for example, a Kayser-Fleischer ring, a brownish-green ring at the perimeter of the cornea might be checked out in patients of Wilson’s disease due to excess copper being deposited in ~ the Descemet’s membrane.<3> The ring deserve to be ideal viewed under a slit-lamp. Peri-orbital plaques as result of lipid deposition called xanthelasmas may be current in chronic cholestasis. Angular cheilitis, inflammatory lesions roughly the edge of the mouth show iron or vitamin deficiency which may be because of malabsorption.<4> The oral cavity must be check in detail. The existence of dental ulcers may suggest Crohn’s disease or celiac disease.<5> A pale, smooth, and shiny tongue show iron deficiency, and also a beefy, red tongue is seen in vitamin B-12 and also folate deficiency. The odor of the patient’s breath is itself indicative of various disorders, for example, fetor hepaticus, a distinctive odor indicating liver disorder, or a fruity breath, pointing towards ketonemia.

The examiner need to stand behind the patience to examine the neck. The is important to palpate because that lymphadenopathy in the neck and also the supraclavicular region. The presence of the Virchow’s node may suggest the possibility of gastric or breast cancer.<6>

The abdominal muscle examination consists of four simple components: inspection, palpation, percussion, and also auscultation.

Four check Components

Inspection of the Abdomen

It is vital to begin with the basic examination of the abdomen v the patience in a completely supine position. The visibility of any type of of the adhering to signs may indicate specific disorders. Distension that the abdomen might be present due to tiny bowel obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation, ab aortic aneurysm, and pregnancy. The visibility of any kind of abnormal masses may indicate umbilical hernia, ventral wall surface hernia, femoral hernia, or inguinal hernia, depending on the location. The patient may be asked come cough, which outcomes in raised intraabdominal pressure, leading to the hernia come become more prominent.

 A job of ecchymosis might be visible on any part of the abdomen ~ above inspection and also usually indicates internal hemorrhage. The ‘Grey Turner sign,’ the ecchymosis of the flank and also groin viewed in hemorrhagic pancreatitis, and also the ‘Cullen"s sign,’ is a periumbilical ecchymosis indigenous retroperitoneal hemorrhage or intra-abdominal hemorrhage. The visibility of scars might be due to surgical or traumatic injuries (gunshot wounds or stab wounds), and also pink-purple striae may suggest Cushing"s syndrome. Vein dilation might be present that indicates portal hypertension or vena cava obstruction. ‘Caput Medusa’ that are distended veins flowing away from the umbilicus,<7> have a 90% specificity in detecting hepatic cirrhosis. Sinuses and also fistulae, if present, usually take place as a an outcome of deep epidemic or an epidemic of a surgical tract. If a stoma is identified, various attributes should be noted to recognize the kind of stoma. These include the size and appearance the the stoma and also the components of the stoma bag.

Palpation that the Abdomen

Ensure the following before beginning the palpation:


The patience is in a supine position, with the head relaxed and also the arms on the side of the body. This is necessary to be sure the abdominal wall surface muscles completely.
The patient has actually mentioned if he is experiencing any kind of pain in the ab area and also has situated the allude of maximal pain.

The ideal position for ab examination is come sit or kneel top top the ideal side of the patient with the hand and forearm in the exact same horizontal airplane as the patient’s abdomen. There room three stages of palpation that include superficial or irradiate palpation, deep palpation, and also organ palpation and should it is in performed in the exact same order. Maneuvers specific to specific diseases are also a component of ab palpation.

The examiner should begin with superficial or light palpation indigenous the area furthest indigenous the allude of maximal pain and also move systematically with the nine regions of the abdomen. If no pain is present, any beginning point can be chosen. Number of sources cite that the abdomen should an initial gently it is in examined with the fingertips. Crepitus, a crunching sensation, if present, indicates the presence of air in the subcutaneous tissue.<8> any type of irregularity in the abdominal wall surface may additionally be noted, which may be because of a hernia or a lipoma.

Deep palpation must be performed in the same position of the hand and also forearm loved one to the patient’s abdomen yet with the applications of firm and also steady pressure. That is vital to press gradually as pressing too rapid may catch a gas pocket in ~ the minister lumen and distend the wall resulting in false-positive tenderness. During palpation, tenderness must be noted, i beg your pardon may present as guarding. This may be a spontaneous process, in i m sorry the patience voluntarily tightens the abdominal muscles to protect a depth inflamed structure, or an involuntary process, wherein the intra-abdominal pathology has evolved to cause rigidity that the abdominal muscle muscles. Engaging the patience in conversation may aid differentiate in between voluntary and involuntary guarding, as the former disappears once the patient"s fist is diverted. Tenderness in any type of of the nine regions of the abdomen may suggest an inflammation the the organs underneath.

Examination the the different areas of the abdomen may suggest separate disease processes. Tenderness of the epigastrium might be due to gastritis or early acute cholecystitis native visceral nerve irritation. Other indications that may be appreciated encompass the visibility of a pulsatile mass native an abdominal aortic aneurysm or abdominal wall surface defects, viewed in muscle diastasis. Left reduced quadrant tenderness may be a presenting authorize of diverticulitis in the elderly. A mass, if present, could be because of a tumor of the colon, a left ovarian cyst, or ectopic pregnancy. In the elderly, constipation top to influenced feces may also present through a mass palpated in the left lower quadrant.

In the right reduced quadrant, tenderness over McBurney"s suggest implies possible appendicitis, inflammation of the ileocolic area that might be because of Crohn disease, or an infection with bacteria that have a predilection because that the ileocecal area together as Bacillus cereus and Yersinia enterocolitica.

If tenderness is evaluate at McBurney’s point, the following maneuvers to identify feasible appendicitis need to be performed:


Obturator sign: This is perform by flexing the patient"s ideal thigh at the hip through the knee flexed and rotating internally. Increased pain at the right reduced quadrant argues inflammation of the interior obturator muscle indigenous overlying appendicitis or one abscess.

The examiner should palpate the periumbilical area for any defect, mass, or umbilical hernia. The patient deserve to be asked come cough or bear under to feel for any protruding mass. The inguinal and the suprapubic area need to not it is in missed. If an inguinal or a femoral hernia is present, a comprehensive examination must be done. A mass palpated in the suprapubic area may be because of a uterine pathology such as uterine fibroids or uterine cancer in females or bladder mass or distension in both males and also females.

The next step is to proceed to palpation that the abdominal organs. Come palpate the liver, the examiner must location the palpating hand listed below the right lower rib margin and also have the patient exhale and then inhale. V mild pressure, the liver margin may be feeling under the hand together a tenderness wave. The is important to feeling for any nodularity or tenderness. Because that palpation that the gallbladder, that is recommended the the examiner gently ar the palpating hand below the right lower rib margin at the midclavicular line and ask the patient to exhale as lot as possible. As the patient exhales, the palpating hand should gradually be propelled in deeper, and the patient have to then be asked to inhale. The sudden cessation that inspiration as result of pain characterizes a confident ‘Murphy sign’ seen in acute cholecystitis.<10> To begin palpating the spleen, the hand must be inserted in the right lower quadrant and also moved toward the splenic flexure. When the hand will the left reduced rib margin, the patient should be asked come exhale and also take a deep breath in. Through mild pressure, the spleen may be feeling under the hand as a firm massive if splenomegaly is present. There are multiple reasons of splenomegaly and must be associated with the patient’s background and various other physical findings.<11>

A two-handed technique with the patience in the supine place is supplied to palpate the kidneys. Come palpate the right kidney, ar the left hand underneath the patient"s back, pushing the kidney forward and also the ideal hand listed below the right reduced rib margin in between the midclavicular and anterior axillary lines, tenderness pushing down. This technique is dubbed ‘balloting.’ to palpate the left kidney, the examiner must lean onto the patient v the left hand placed roughly the flank right into the patient"s loin and also place the best hand ~ above the abdomen below the left lower rib margin in between the mid-clavicular line and also the anterior axillary line. Enlarged or cystic kidneys may be appreciated making use of this technique.

To estimate the dimension of the aorta, the patient should be asked come lie under supine and fully relax the abdominal wall surface muscles. A two-handed method is preferred, with the left and right hands put along the lower boundaries of the left and also right costal margins, respectively, and the finger pointing towards the umbilicus. A generosity amount of skin should be left in between the 2 index fingers. The aorta have the right to be palpated together a pulsatile mass, and its width deserve to be recorded. A width greater than 2.5 cm suggests an aneurysm, and an ab ultrasound must be performed to inspection it further. However, one enlarged aneurysm may still not be evaluate by palpation as result of body habitus.

Percussion of the Abdomen

A proper method of percussion is vital to get maximum info regarding abdominal muscle pathology. While percussing, it is vital to evaluate tympany over air-filled structures such together the stomach and also dullness come percussion, which might be present due come an basic mass or organomegaly (for example, hepatomegaly or splenomegaly). To evaluate splenic enlargement, the percussion the the Castell"s point (the many inferior interspace ~ above the left anterior axillary line) together the patience takes a deep motivation may be helpful. A percussion keep in mind that transforms from tympanitic come dull together the patient takes a deep breath suggests splenomegaly, with an 82% sensitivity and an 83% specificity. Splenomegaly wake up in trauma through hematoma formation, portal hypertension, hematologic malignancies, epidemic such as HIV and also Ebstein-Barr virus, and also splenic infarct.<12>

Percussion is vital to assess the size of the liver, percussion bottom from the lung to the liver, and then the bowel; the examiner may be able to demonstrate the readjust in percussion note from resonant to dull and then tympanitic. Changing dullness, present in ascites, must be demonstrated by percussing native the midline to the flank till the note changes from dull come resonant and then having actually the patient roll over on their side in the direction of the examiner and also wait for ten seconds. This permits any fluid, if present, to relocate downwards. The percussion have to then be repeated, moving in the exact same direction. If the percussion note transforms to resonant, moving dullness room positive.<13><14> With the patient sit up, the right and left costal-vertebral angles have the right to be percussed to determine if there is any type of renal tenderness as in pyelonephritis.

Auscultation the the Abdomen

The last step of the ab examination is auscultation with a stethoscope. The diaphragm that the stethoscope must be put on the right side that the umbilicus to hear to the bowel sounds, and also their rate must be calculated after ~ listening because that at least two minutes. Regular bowel sounds are low-pitched and also gurgling, and also the rate is typically 2 to 5/min. Missing bowel sounds may indicate paralytic ileus, and hyperactive rushes (borborygmi) room usually existing in small bowel obstruction and sometimes can be auscultated in lactose intolerance.<15>

The diaphragm have to be placed above the umbilicus to hear for an aortic bruit and also then relocated 2 cm over and lateral to the umbilicus to hear for a renal bruit. The presence of the former indicates an ab aortic aneurysm, and also the latter shows renal artery atherosclerosis.<16> These clinical findings should be associated with the remaining physical check and background to formulate a preliminary diagnosis. If over there is a clinical hesitation of delay gastric emptying, a maneuver that is occasionally uncomfortable for the patient might be performed; the examiner should location the stethoscope on the abdomen and hold the patient at the hips and shake him from next to side. If splashing sounds, referred to as the ‘succussion splash,’ are audible, the check is positive.

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Digital Rectal Examination

The abdominal examination ends v the digital rectal examination. ~ explaining the procedure, acquisition the patient’s consent, and maintaining the patient’s privacy, the rectal examination must be carry out with ideal technique. The examiner should place their lubricated, gloved finger against the patient’s rectal sphincter muscle to dilate the sphincter and gradually slide it right into the rectum palpating because that hemorrhoids, fissures, or international bodies. The prostate because that size and also firmness should be assessed. Tenderness or bogginess says prostatitis, and also nodules may suggest cancer. After ~ the finger is removed, it must be inspected for signs of active bleeding or melena. Do a Guaiac check if bleeding is suspected. Check of the exterior genitalia should additionally be performed.