“Hello my name is , a nursing student at USA. Let’s start your abdomen exam.”
“Please lie down on the exam table with your arms at your sides. I’ll place one pillow under the head and a second pillow under the knees.”
Inspect. “The skin is a uniform tan-pink color. It is smooth with no scars, striae or other lesions. There is an even distribution of fine, vellus hair and a few small moles. No veins are visible. The umbilicus is midline and inverted with no sign of inflammation.”
Inspect. Stand on the patient’s right side, and bend down to determine the abdomen’s profile. “The abdominal profile is flat (or scaphoid, rounded or protruberant).” Stand and continue inspecting. “The abdomen is bilaterally symmetric with no visible hernias, masses or distention. A slight aortic pulsation is noted. Peristalsis waves are not visible.”
Auscultate. “Now we will auscultate for bowel sounds. We do this before palpating and percussing the abdomen so we do not artificially increase peristalsis. I will warm the stethoscope with my hands. Hold the stethoscope using the diaphragm to listen for a few seconds in each of four quadrants. I will start at the RLQ because bowel sounds are normally always present.” Listen at the RLQ, RUQ, LUQ, LLQ. “Audible bowel sounds are noted in all four quadrants. A lack of bowel sounds would be abnormal. I would listen for 5 minutes in each quadrant to determine if the bowel sounds are completely absent.”
Auscultate. “Now I will use the bell of the stethoscope and firmer pressure to detect the presence of bruits over the aorta, renal arteries, and iliac arteries.” Auscultate. “No bruits present. A bruit is a whoosing sound that indicates turbulent blood flow. It occurs with stenosis or occlusion of an artery.”
Percuss lightly in all four quadrants (in a zig-zag, upside-down U pattern using hands or hammer) to determine the relative amount of tympany and dullness. “There is tympany in all four quadrants. This is expected because air in the intestines rises to the surface when the patient is supine.”
Percuss to measure the height of the liver in the right midclavicular line. Begin in the area of lung resonance and percuss down the interspaces until the sound changes to dullness in the 5th intercostal space. “Resonance, resonance, dullness.” Mark the spot with a pen. Then find abdominal tympany and percuss upwards until the sound changes to dullness at the right costal margin. “Tympany, tympany, dullness.” Mark the spot and measure the distance. “The liver measures 7cm, which is within the normal range for an adult female. In males, normal is about 10.5 cm. An enlarged liver or hepatomegaly occurs with diseases such as hepatitis or cirrhosis.”
Percuss for a dull note from the 9th to 11th intercostal space just behind the left midaxillary line.“Splenic dullness can sometimes be percussed from the 9th to 11th intercostal space just below the left midaxillary line. The area is normally not wider than 7cm.” “Tympany, tympany, tympany. Splenic dullness was not detected. A dull note before the midaxillary line indicates enlargement of the spleen. Please take a deep breath.” Percuss in the lowest interspace in the left anterior axillary line. You should hear tympany. “Tympany is noted. This is a normal result. A change in percussion from tympany to a dull sound would indicate mild to moderate splenomegaly before the spleen becomes palpable. This can occur with mononucleosis or trauma.”
Percuss.“Now I’d like you to please sit up for me, keeping your arms at your sides so we can examine your kidneys. Please let me know if you feel any pain or tenderness.” Place your left hand over the 12th rib at the costovertebral angle on the back. Thump that hand with the ulnar edge of your right fist. “No pain or tenderness noted at the costavertebral angle. Sharp pain would occurof there was inflammation.”
Palpate. “Now I’d like you to lie down again, and bend your knees and keep your arms at your sides. Touch the patient’s abdomen and forehead with the back of your hand. “The temperature of the abdomen is normal and consistent with the rest of the body.”
Palpate. “Breathe deeply, relax, and tell me if you feel any tenderness.” Keep your four fingers close together, and depress the skin 1cm with a gentle rotary motion. Start at 12 o’clock and move around the abdomen in a clockwise direction. “The abdomen is not tender. There is normal muscle tone and rigidity. There may normally be some tenderness around the cecum and sigmoid colon.”
Palpate. “Keep breathing deeply, and tell me if you feel any tenderness.” Push down 2-3" (5-8 cm), using the same circular motion to explore the entire abdomen, moving clockwise starting at 12 o’clock. “No enlargements, tenderness or masses noted.”
Palpate. “Now we will palpate the aortic pulsation.” Using your thumb and fingers pinch a small amount of skin just above the umbilicus slightly to the left of midline. Pinch a small amount of skin about an inch above the umbilicus to feel the aortic pulsation. “The aortic pulsation is noted.”
Palpate. “Now we will palpate the border of the liver.” Stand at the patient’s right side. Place your left hand under the patient’s back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. Place your right hand on the RUQ with fingers parallel to the midline. Push down deeply and under the right costal margin. “Please take a deep breath. Now let the air out and relax” Feel under the rib. The edge of the liver bumps your finger tips as the diaphragm pushes it down during inhalation. But often the liver is not palpable and nothing firm is felt. “The liver is non palpable.”
Palpate. “Now we will palpate the spleen. Normally the spleen is not palpable and must be enlarged to three times it’s normal size to be felt. An enlarged spleen can rupture if overpalpated.” Reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift up for support. Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left costal margin. “Please take a deep breath. The spleen is not palpable.”
