Abdominal Examination Overview

Overview

This lecture covers the objective physical examination of the abdomen, focusing on the unique order of assessment, types of findings, and key terminology.

Order of Abdominal Assessment (IAPP)

• The abdominal exam uses a unique order: Inspect, Auscultate, Percuss, Palpate (IAPP).
• Auscultation is done before palpation/percussion to avoid altering bowel sounds.

Inspection

• Inspect the bare abdomen for contour (shape) from rib cage to hipbones.
• Common contours: flat (straight line), scaphoid (sunken), rounded, and protuberant (bulging).
• A protuberant abdomen is normal in toddlers and late pregnancy.
• Assess for symmetry, bulges, pulsations, hernias, skin tone, scars, tattoos, piercings, and stretch marks (striae).
• New, reddish striae may indicate recent abdominal enlargement, such as from ascites.

Auscultation

• Start auscultation in the right lower quadrant and move clockwise.
• Listen to 3-4 sites in each quadrant using the diaphragm for 1–1.5 minutes per quadrant.
• Normal bowel sounds: 5-30 clicks and gurgles per minute (normoactive).
• Absent bowel sounds require listening for 5 minutes per quadrant.
• Hyperactive (increased) and hypoactive (decreased) bowel sounds indicate different conditions (e.g., diarrhea, post-op, immobility).
• Borborygmi are very loud, growling bowel sounds (hunger).
• Listen for bruits with the bell at the abdominal aorta; a bruit suggests turbulent blood flow (e.g., AAA).

Percussion

• Use indirect percussion in a zigzag pattern, 3-4 spots per quadrant.
• Typical percussion note for the abdomen is "tympany" (drumlike sound).
• Dullness could indicate fluid, mass, or enlarged organs.
• Percuss for costovertebral angle (CVA) tenderness to assess for kidney pain, infection, or stones.

Palpation

• Perform light palpation first (1-2 cm deep) for tenderness, muscle tone, or superficial masses.
• Deep palpation (about 3 inches) checks for deep masses, organomegaly, or tumors.
• Start in the quadrant opposite any area of pain; examine the tender area last.
• Liver palpation uses bimanual or hooking technique—should feel only a slight tap and no pain.
• The gallbladder should not be palpable unless inflamed.

Key Terms & Definitions

• Contour — shape of the abdomen (flat, scaphoid, rounded, protuberant)
• Normoactive — normal bowel sounds (5-30/min)
• Hyperactive — more than normal bowel sounds
• Hypoactive — fewer than normal bowel sounds
• Borborygmi — loud, growling bowel sounds
• Illeus — absence or significant reduction of bowel sounds
• Tympany — typical drumlike percussion sound of the abdomen
• CVA tenderness — pain elicited at the costovertebral angle, can indicate kidney issues
• Organomegaly — enlargement of an organ

Action Items / Next Steps

• Memorize and practice the IAPP order for abdominal exams.
• Review abdominal contour types and their clinical significance.
• Know normal vs. abnormal bowel sound characteristics.
• Practice light and deep palpation techniques and liver assessment methods.

In the abdominal exam, the abdomen is divided into four quadrants to help localize findings during inspection, auscultation, percussion, and palpation. Here’s what you generally find or assess in each quadrant:

1. Right Lower Quadrant (RLQ)

• Key organs: Appendix, cecum, part of the ascending colon, right ovary and fallopian tube (in females), right ureter.
• Clinical relevance: Common site of appendicitis pain; important to start auscultation here because bowel sounds often are most active in this area.

2. Right Upper Quadrant (RUQ)

• Key organs: Liver (majority), gallbladder, part of the ascending colon, duodenum, head of the pancreas, right kidney (posterior).
• Clinical relevance: Palpate for liver size and tenderness; assess for gallbladder inflammation; listen for bruits over the abdominal aorta near this area.

3. Left Upper Quadrant (LUQ)

• Key organs: Stomach, spleen, part of the transverse and descending colon, body and tail of the pancreas, left kidney (posterior).
• Clinical relevance: Assess for splenomegaly (enlarged spleen), stomach tenderness, and masses.

4. Left Lower Quadrant (LLQ)

• Key organs: Part of the descending colon, sigmoid colon, left ovary and fallopian tube (in females), left ureter.
• Clinical relevance: Common site for diverticulitis pain; assess for tenderness or masses.

General Notes on Quadrants in the Exam:

• Auscultation: Start in the RLQ and move clockwise through all quadrants because bowel contents move in that direction.
• Percussion and Palpation: Also proceed in a clockwise zigzag pattern through all quadrants.
• Tender areas: If a patient has pain in a specific quadrant, save palpation of that quadrant for last to avoid guarding.

If you want, I can help you with more details about what specific findings in each quadrant might indicate!