Basic Clinical Skills
Richard Rathe, MD
October 15, 1995
Copyright 1995 by the
University of Florida
Most of the abdominal organs are found within the peritoneum. These organs can and do "move" (during pregnancy for example). Certain structures, such as the kidneys and pancreas, are retroperitoneal.
Caveat - Remember that the position of the appendix is highly variable. In addition to its "normal" position it can be found against the abdominal wall (anterior), below the pelvic brim (pelvic), behind the cecum (retrocecal), or behind the terminal ilium (retroilial). The pain associated with appendicitis varies with the anatomy.
Inspection
Auscultation
Percussion
Palpation
Special Tests
Inspection is always an important first step in any physical examination. Look at the abdominal contour and note any asymmetry. Record the location of scars, rashes, or other lesions.
Unlike other regions of the body, auscultation comes before percussion and palpation (the sounds may change after manipulation). Record bowel sounds as being present, increased, decreased, or absent.
In addition to bowel sounds, abdominal bruits are sometimes heard. Listen over the aorta, renal, and iliac arteries. Bruits confined to systole do not necessarily indicate disease. Don't be fooled by a heart murmur transmitted to the abdomen.
Tympany is normally present over most of the abdomen in the supine position. Unusual dullness may be a clue to an underlying abdominal mass.
Measure the liver span by percussing hepatic dullness from above (lung) and below (bowel). A normal liver span is 6 to 12 cm in the midclavicular line.
To detect an enlarged spleen, percuss the lowest interspace in the left anterior axillary line. Ask the patient to take a deep breath and repeat. A change from tympany to dullness suggests splenic enlargement.
Begin with light palpation. At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression. Voluntary or involuntary guarding may also be present.
Proceed to deep palpation after surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness.
To palpate the liver edge, place your fingers just below the costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against or slide under your hand. A normal liver is not tender.
An alternate method for palpating the liver uses hands "hooked" around the costal margin from above. The patient should be instructed to breath deeply to force the liver down toward your fingers.
The aorta is easily palpable on most individuals. You should feel it pulsating with deep palpation of the central abdomen. An enlarged aorta may be a sign of an aortic aneurysm.
Press down just below the left costal margin with your right hand while asking the patient to take a deep breath. It may help to use your left hand to lift the lower rib cage and flank. The spleen is not normally palpable on most individuals.
These tests are useful in special situations:
This is a test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.
CVA tenderness is often associated with renal disease. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.
If dullness on percussion shifts when the patient is rolled on the side, peritoneal fluid (ascites) may be present.
Thank You