Before assessing the abdomen, consider the patient's history. If he reported abdominal pain, plan to examine the painful area last. If he has a full bladder, have him void to encourage relaxation.
During this part of the exam observe the patient's face regularly for signs of pain or guarding. Start by inspecting the abdomen from the ribs to the symphysis pubis. Its contour should be symmetrical. To highlight any bulges, shine a light across the abdomen toward you. No bulges should be visible. Assess the umbilicus, which should be midline and inverted.
Next, auscultate the abdomen. Always auscultate the abdomen before percussing and palpating it because these actions can make bowel sounds more active than normal. Begin by placing the stethoscope's diaphragm lightly on the right lower quadrant. Because the ileocecal valve is in this quadrant bowel sounds are usually audible here. Listen for at least two minutes. Assess bowel sounds in all four quadrants. Determine if the sounds are normal, hyperactive, hypoactive, or absent. Be sure to listen for five minutes before concluding that they're absent.
Now auscultate for vascular sounds by switching to the bell of the stethoscope and listening over the aorta, renal arteries, iliac arteries, and femoral arteries. Listen for bruits, which may be heard during systole. Bruits are abnormal. Next, percuss in a systematic fashion. You should hear dullness over the solid organs and tympani over the air-filled organs. You may also hear dullness over a distended bladder, adipose tissue, fluid collection, or a mass. You may hear hyperresonance over a gas-distended organ.
Now percuss each organ, beginning with the liver. To assess the liver, percuss from the right lung area down the midclavicular line until you hear dullness. Mark this point, which is the upper border of the liver. It's usually located at the 5th intercostal space. Then percuss up the midclavicular line from the umbilical level until you hear dullness. Mark this point, too, which indicates the liver's lower border. It should be at the right costal margin. Measure the distance between the two marks to estimate the size of the liver, which should be 6–12 centimeters.
Now assess the stomach by percussing over the left upper quadrant. Percussion here should produce tympani.
Next, have the patient roll onto his right side. Assess his spleen by percussing from the 6th rib down the midaxillary line. Expect to hear dullness between the 9th and 11th intercostal spaces. Now percuss at the lowest intercostal space in the anterior axillary line, where you should hear tympani. Then ask the patient to take a deep breath and percuss again. You should still hear tympani.
Doctor: I believe that's fine. You can roll back.
Woman: If you suspect patient has a urinary problem, percuss the bladder. Start at a point 5 centimeters above the symphysis pubis and continue to percuss downward. You should hear tympani over an empty bladder or dullness over a full one.
Next, lightly palpate the abdomen, avoiding only the tender areas. Using your fingertips, palpate the right lower quadrant and then move clockwise to all four quadrants. Now switch to deep palpation. Following the same palpation sequence you used for light palpation, push in 5–8 centimeters. Note the size, location, consistency, and mobility of the abdominal organs. You should detect no tenderness, enlargements, or masses; however, mild tenderness over the sigmoid colon is normal. If deep palpation proves difficult, such as in an obese patient, use bi-manual palpation.
To palpate the liver, slide your left hand under the patient along the 11th or 12th rib and push up. Place your right hand on the right upper quadrant and push your fingers down and under the right costal margin. Ask the patient to take a deep breath and feel for the firm liver to move down with inspiration. Now try to palpate the gallbladder using the regular technique you used for the liver. Normally the gallbladder isn't palpable. If it's enlarged, you'll feel it below the liver. Try to palpate the spleen next. Reach over the patient, place your left hand behind his back at the 10th to 12th ribs and push up. Place your right hand just below the left costal margin. As you push your right hand in and up toward the axilla, have the patient take a deep breath. Normally, the spleen is not palpable.
If a bladder problem is suspected you'll need to assess the bladder. Place both hands in the midline 2 ½ centimeters above the symphysis pubis. Palpate in an upward direction until you feel the edge of the bladder. A normal bladder may not be palpable. Now palpate the right kidney by placing your left hand under the patient's waist below the 12th rib and your right hand directly above it. Tell the patient to take a deep breath and bring your hands together as he does this. If the kidney's palpable, you should feel a small, round mass slide between your fingers.
Palpate aortic pulsations by placing your thumb and index finger left of the midline. Estimate the pulsation's width, which should be 2 ½ to 4 centimeters. Now, test the patient's abdominal superficial reflex. To do this, stroke the handle of the reflex hammer or the wooden end of a cotton-tipped applicator across his abdomen, from the side to the midline. Normally, muscles on the stroked side contract and the umbilicus deviates toward the stroked area.