Clinical Skills: Abdominal Assessment

Hello! This video covers how to do an abdominal assessment. In a normal examination you’d do everything on this list, but to keep things concise this video will focus on the steps in blue and will also cover: special populations like infants, children, and the elderly; and include a summary.

Meet Fred. Before we go into inspecting his abdomen, let’s make sure that he’s comfortable. Fred’s already emptied his bladder and we’ve kicked up the heat a notch in the room. Let’s put a pillow under his knees, too. Fred, do you have any abdominal pain we should know about? Let’s leave those areas till last.

Fred’s abdomen is flat, but if it were a little rounded that would be ok too. It’s pretty symmetrical, as well. If we ask Fred to breathe in and hold his breath, there are no bumps or bulges, nor is there any muscle separation.

The umbilicus, navel, or belly button isn’t red or swollen, and the skin is nice and smooth. Overall, Fred looks well: he’s comfortable and breathing normally; but what if he didn’t?

His abdomen could be scaphoid, where it caves in, that usually indicates malnutrition. It could be also protuberant, where it sticks out, which may be caused by excess fat or ascites. There could be bulges, like a hernia. The skin could be a little yellow or green, suggesting jaundice, or there could be areas of discoloration following bruising. Veins might be sticking out due to malnutrition or cirrhosis, or you might see striae - stretch marks - which could be due to rapid growth, pregnancy, cirrhosis, or Cushing syndrome.

Now let’s auscultate Fred’s abdomen. Percussion and palpation stimulate peristalsis, so we always auscultate the abdomen first. With the diaphragm endpiece, gently hold the stethoscope against Fred’s skin.

Let’s start in the right lower quadrant. Bowel sounds are most common here, and sound like high-pitched gurgling, every few seconds. You don’t have to hear sounds in each quadrant. As long as there are some sounds somewhere with pauses, that’s okay. Stomach growling, or borborygmus, is normal if you’re hungry. Constant, continuous bowel sounds is not - that’s associated with increased motility and might indicate gastroenteritis or the early stages of abdominal obstruction. Absent bowel sounds are defined as 5 minutes with no bowel sounds at all - they’re a late sign of abdominal obstruction. Listening with the bell of a stethoscope, you might also hear some quiet vascular sounds, or bruits, which are normal in the abdomen.

It’s time to percuss, or tap on, Fred’s abdomen. Percussion lets us determine if there is air, fluid, or dense tissue 5 to 7 centimeters under the area we are percussing.

To percuss, place the middle finger of one hand on the area you wish to percuss, and separate the other fingers away from it. Apply moderate pressure with the middle finger to create a good seal. Don’t let the other fingers rest. Strike the phalanx of the middle finger with the tip of the middle finger of your other hand using a quick, sharp, relaxed wrist motion. The striking finger should be flexed.

Remember, the key is to keep your hand relaxed and the motion is all in the wrist.

Practice at home on yourself, friends, or on objects like the walls of your home. There are five musical notes you can hear during percussion. If you’re practicing on yourself, you can hear four of the five.

A flat sound is a soft, high-pitched, short sound that can be heard when percussing the thigh. Flat sounds can be heard when percussing bone or muscle.

A dull sound is moderately loud, lower in pitch and longer in duration than a flat sound, and can be heard when percussing the liver. These sounds are typically heard over solid or fluid-filled areas.

A resonant sound is a loud, low-pitched, long sound that can be heard over the lung. Resonant sounds are often heard in air-filled areas, like the lung.

A hyperresonant sound is more like a drum. Listen for a really low-pitch, echo or booming sound. You can’t recreate this on a healthy patient, but remember it’s louder, lower, and longer, than a resonant sound.

A tympanic sound is a loud, high-pitch, long sound that can be heard by percussing the gastric air bubble or a puffed cheek.

Alright, now let’s percuss the abdomen. We’ll do all four quadrants lightly, listening for a tympanic sound as air in the gut rises up while Fred is supine. If there’s dullness, that could signal bladder distension, adipose tissue, or other fluids or masses like organs.

Let’s measure the liver. Starting around the height of the nipple, on the right midclavicular line, gently percuss downwards until the sound goes dull - that’s the upper border of the liver. Now, find an area of abdominal tympany on the midclavicular line, and percuss upwards until the sound goes dull - that’s the lower border of the liver. The span of the liver should range from about 6 to 12 centimetres, but could be bigger in cases of hepatomegaly.

In some cases, you can also locate the lower edge of the liver by using a scratch test. Placing a stethoscope on the xiphoid, we run a finger up the midclavicular line from the right lower quadrant, parallel to the liver border, lightly scratching the skin. When you hit the liver, the sound in the stethoscope gets louder.

Similarly, you can find the spleen by percussing for dullness between the 9th and 11th intercostal spaces, behind the left midaxillary line. Also, ask Fred to take a deep breath while you percuss the 11th intercostal space, along the anterior midaxillary line. This should be tympanic, but if it turns dull when Fred breaths in, that may suggest splenomegaly.

If Fred sits up, we can also percuss for his kidneys. Just place a hand over the 12th rib at the costovertebral angle, and gently strike it with the ulnar surface of your fist. Fred should feel the tap, but no pain - which would signal inflammation of the kidney or musculoskeletal tissue.