M1 H&P: The Abdominal Exam

Devin Nickol, M.D.

I. Inspection

- Describe abdominal contour:

- Protruberant
- Distended
- Flat
- Scaphoid

- Recognize abdominal landmarks:

- Costal margin
- Midline
- Umbilicus
- Poupart's ligament
- Xiphoid process of sternum
- Anterior superior iliac spine
- Superior margin of os pubis

- Describe locations by quadrant and know the contents of each quadrant:

- Right upper quadrant

- Liver and gallbladder
- Pylorus
- Duodenum
- Head of pancreas
- Right adrenal gland
- Portion of right kidney
- Hepatic flexure of colon
- Portions of ascending and transverse colon

- Left upper quadrant

- Left lobe of liver
- Spleen
- Stomach
- Body of pancreas
- Left adrenal gland
- Portion of left kidney
- Splenic flexure of colon
- Portions of transverse and descending colon

- Right lower quadrant

- Lower pole of right kidney
- Cecum and appendix
- Portion of ascending colon
- Bladder (if distended)
- Ovary and salpinx
- Uterus (if enlarged)
- Right spermatic cord
- Right ureter

- Left lower quadrant

- Lower pole of left kidney
- Sigmoid colon
- Portion of descending colon
- Bladder (if distended)
- Ovary and salpinx
- Uterus (if enlarged)
- Left spermatic cord
- Left ureter

- Describe locations by region and know the contents of each region:

- Right hypochondriac
- Right lobe of liver
- Gallbladder
- Portion of duodenum
- Hepatic flexure of colon
- Portion of right kidney
- Suprarenal gland
- Epigastric
- Pyloric end of stomach
- Duodenum
- Pancreas
- Portion of liver
- Left hypochondriac
- Stomach
- Spleen
- Tail of pancreas
- Splenic flexure of colon
- Upper pole of left kidney
- Suprarenal gland
- Right lumbar
- Ascending colon
- Lower half of right kidney
- Portion of duodenum and jejunum
- Umbilical
- Omentum
- Mesentery
- Lower part of duodenum
- Jejunum and ileum
- Left lumbar
- Descending colon
- Lower half of left kidney
- Portions of jejunum and ileum
- Right inguinal
- Cecum
- Appendix
- Lower end of ileum
- Right ureter
- Right spermatic cord
- Right ovary
- Hypogastric (pubic)
- Ileum
- Bladder
- Uterus (in pregnancy)
- Left inguinal
- Sigmoid colon
- Left ureter
- Left spermatic cord
- Left ovary

 

II. Auscultation

- Auscultate for bowel sounds:

- Normal frequency is _____________ sounds per minute
- Must listen for ___ full minutes to say bowel sounds are absent
- Listen in all 4 quadrants
- Recognize borborygmi: loud, prolonged gurgles which are audible without a stethoscope

- Auscultate for abnormal vascular sounds:

- Listen for bruits with the diaphragm over abdominal arteries:

- Renal
- Iliac
- Femoral

- Listen for venous hum with the bell over the epigastrium (a marker of portal hypertension)

III. Percussion

- Assess the size of abdominal organs

- Liver
- Spleen

- Understand the normal percussion tone for a given region:

Tympany: Musical note of higher pitch than resonance, found over ______________________________________

Hyperresonance: Pitch lies between tympany and resonance, found over ___________________________________________________

Resonance: Sustained note of moderate pitch, found over ___________________________________________________

Dullness: Short, high-pitched note with little resonance, found over _________________________________________________________

IV. Palpation

- Use proper technique for palpation

- Light
- Moderate
- Deep
- Palpate tender areas last
- Have the patient lift their head to differentiate intra-abdominal from extra-abdominal masses
- Palpate specific abdominal organs:
- Liver
- Spleen
- Gallbladder
- Kidneys
- Aorta

V. Other maneuvers

- Assess liver size with scratch test

- Check for diastasis recti

- Evaluate for ascites:

- Shifting dullness
- Fluid wave

- Evaluate for peritoneal signs:

- Guarding
- Rebound
- Rigidity

- Diagnose appendicitis

- Iliopsoas test

- Obturator test

- Diagnose cholecystitis

- Murphy's sign

- Percuss for costovertebral angle tenderness