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.If Fred is unable to sit up, we can do the same test with him lying on his side.

We can check for ascites by percussing for shifting dullness. With Fred lying on his back, percuss across the abdomen to find the border between tympany and dullness.

If we roll Fred onto his side, the border should stay in roughly the same place. If the dullness shifts towards the lower side, that often signals ascites, and here’s what that sounds like.Also test for a fluid wave.

Ask Fred or an assistant to secure the midline of the abdomen with the edge of one or both hands, and place two hands on either side of the abdomen.

Tap sharply with one hand. An impulse felt in the second hand is indicative of the fluid wave, and is also a sign of ascites.Before we start palpation, let’s get Fred comfortable.

First, make sure Fred’s had a chance to empty his bladder, as palpation can be uncomfortable if the bladder is distended.

Bend Fred’s knees, and encourage him to breathe slowly. Let him know we’re going to use light pressure to palpate his abdomen, followed by deeper pressure.

If he feels any discomfort, he can tell us.Palpate the abdomen using four fingers, press the abdomen down by about a centimeter, and rotate your fingers in a circular motion.

If Fred were obese, we could press down with a second hand - that would be the two hand technique. Move your fingers clockwise around the abdomen in all four quadrants as you get an impression for his skin and musculature.

There shouldn’t be any tenderness, masses, or rigidity.Now, that was light palpitation. Pressing in a little further - say 5 to 8 centimetres - you can get a feel for the deeper tissues.We’ll also palpate for specific organs.

For the liver, the left hand goes underneath the back - along the 11th and 12th ribs - supporting the abdomen, while the right hand palpates the right upper quadrant.

Pushing deep under the costal margin, ask Fred to breathe in and then out. You may feel the liver brush against your hand as Fred inhales.

It should feel firm and smooth.Alternatively, you can also stand by the shoulder, and dig - or hook - your fingers in and over the costal margin.

Ask Fred to take a deep breath and see if you feel it.For the spleen, the left hand goes over the abdomen and loops around, underneath the back - also along the 11th and 12th ribs - supporting the abdomen.

Meanwhile the right hand palpates the left upper quadrant with fingers angled towards the armpit, as Fred takes a deep breath.

Nothing firm here, so no spleen enlargement. If we did feel enlargement, that could signal portal hypertension, various infections, or blood malignancies.For the right kidney: put your hands together and squeeze into the right flank while Fred inhales.

You may or may not feel the kidney. For the left kidney, the left hand goes over the abdomen and underneath the left flank, supporting the abdomen, while the right hand palpates.

Even though Fred is breathing deeply, we usually won’t feel the left kidney anyways. We can also attempt to palpate the bladder, just above the symphysis pubis.

However, you won’t feel it unless the bladder is distended with urine.Finally, for the aorta, use the thumb and fingers to palpate the upper abdomen a little to the left of the midline.

Alternatively, use two hands pressing inwards against each other. The aorta is usually about two and a half to four centimeters wide, pulsating in an anterior direction.

A strong lateral pulsation might indicate an aortic aneurysm.If there was tenderness or pain, we would check for rebound tenderness with the Blumberg Sign.

Away from any painful areas, we push one hand perpendicular into the abdomen, slowly and gently. Pulling the hand away quickly, we see if Fred experiences any pain.

Pain would suggest peritoneal inflammation, often accompanying appendicitis.Another test is the Murphy sign, which shows up with inflammation of the gallbladder.

With fingers under the liver border, Fred takes a deep breath. If there’s pain, Fred gasps, or Fred flinches, that’s a positive result for the test.We can quickly do the iliopsoas muscle test, too, for appendicitis.

With Fred’s right leg raised upwards, we push down on the thigh as he resists. Like before, if pain is felt in the abdomen, that’s a positive result for the test.If you detected any abdominal masses earlier in our assessment, you can try to feel for them using the ballottement test.

With your fingers straight and stiff, quickly and briefly push onto the abdominal surface. This pushes fluid out of the way, giving you a chance to touch the surface of the mass.We can palpate the appendix by finding McBurney’s point.

Palpate the right anterior-superior iliac spine with our fingers. From this location, we can draw an imaginary line to the umbilicus.

McBurney’s point is one third of the way up the imaginary line we just drew. Pain when palpating McBurney’s point might indicate appendicitis.For kids, the abdomen is often a little protuberant.The skin has a light venous pattern.

There might be two bulges, but they’re symmetrical. If there’s an umbilical hernia, that’s OK if it’s two and a half centimetres or smaller.

However, it should be watched to ensure it doesn’t continue growing.There may be some pulsations in the epigastric area, but visible peristaltic waves could indicate pyloric stenosis.When auscultating in children, it’s usually just bowel sounds - nothing vascular.

With percussion, it’s mostly tympany. It might be dull over the liver or bladder, but we don’t percuss the spleen.

If palpating, remember to support the child’s leg or arm.