1. Examination of the Abdomen
Health Assessment
Examination of the Abdomen

2. Introduction:
The anatomy and physiology review of the abdomen has a two-point focus:
The primary focus: the gastrointestinal system.
The secondary focus: abdominal structures of other systems.
The gastrointestinal system consists of the alimentary canal and the accessory digestive organs.
The canal is formed from the mouth, pharynx, esophagus, stomach, small intestines, and large intestines.
The accessory organs include the teeth, salivary glands, liver, gallbladder, and pancreas.

3. Introduction: The esophagus: The stomach:
Connects the pharynx to the stomach, 25 cm length.
The stomach:
Extends from the esophagus at the cardiac sphincter to the duodenum at the pyloric sphincter, located in the left side of the upper abdomen, the stomach is directly inferior to the diaphragm.
The primary function of the stomach is chemical and mechanical breakdown of food.

4. Introduction: The small intestine:
Is the body's primary digestive and absorptive organ.
Approximately 2 m in length.
It has three subdivisions:
The duodenum.
The jejunum.
The ileum.
Intestinal juice, bile from the liver and gallbladder, and pancreatic enzymes mix with the chime to promote digestion and facilitate the absorption of nutrients

5. Introduction: Large intestine:
Extends from the ileocecal valve to the anus.
The main functions of the large intestines are:
Absorbing water from indigestible food residue.
Eliminating the residue in the form of feces.
ـــConsists of:
The cecum.
Ascending colon.
Transverse colon.
Descending colon.
Sigmoid colon.
Rectum.
Anus.

6. Introduction:
Liver:
Located in the right upper portion of the abdominal cavity directly inferior to the diaphragm and extends to the left side of the abdomen.
Has many metabolic and regulatory functions.
The only digestive function of the liver is producing and secreting bile for fat emulsification.

7. Introduction: Gallbladder: Pancreas: A storage organ for bile.
It releases stored bile into the duodenum when stimulated.
Pancreas:
Triangular-shaped gland located in the left upper portion of the abdomen.
Pancreatic juice, which contains a broad spectrum of enzymes, mixes with bile in the duodenum.
The main function of the pancreas is assisting with the digestion of proteins, fats, and carbohydrates.

8. Introduction: Abdominal aorta:
It starts from T12 level and continues to the L4 level where it bifurcates to form the right and left common iliac arteries.

9. Introduction: Kidneys, ureters, bladder:
The kidneys lie within the abdomen, behind the peritoneum.
Kidneys are responsible for the filtration of nitrogenous wastes and the production of urine.
The ureters carry urine from the kidneys to the urinary bladder.
The urinary bladder is located in the pelvis. The primary function of the bladder is to store urine until it can be released.

10. Introduction: Spleen:
The largest of the lymphoid organs, located in the left upper portion of the abdomen, directly under the diaphragm.
It filters and cleanse blood, destroying worn-out red blood cells and returning their breakdown products to the liver.

11. Landmarks: Xiphoid process. Umbilicus. Costal margin. Iliac crest.
Pubic bone.

12. Landmarks: Mapping the abdomen into 4 quadrants:
Extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone.
Draw a horizontal line through the umbilicus.
The quadrants are named: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), and left lower quadrant (LLQ).

13. Right upper quadrant:
Liver & gallbladder.
Pyloric sphincter.
Duodenum.
Head of pancreas.
Right adrenal gland.
Portion of the right kidney.
Hepatic flexure of the colon.
Portion of ascending and transverse colon.
Left upper quadrant:
Left lobe of the liver.
Spleen.
Stomach.
Body of pancreas.
Left adrenal gland.
Portion of the left kidney.
Splenic flexure of colon.
Portion of transverse and descending colon.
Right lower quadrant:
Lower pole of right kidney.
Cecum and appendix.
Portion of ascending colon.
Ovary and uterine tube.
Right spermatic cord.
Right ureter.
Left lower quadrant:
Lower pole of left kidney.
Sigmoid colon.
Portion of descending colon.
Left spermatic cord.
Left ureter.

14. Landmarks: Mapping the abdomen into 9 regions:
Extend the right and left midclavicular lines to the groin.
Draw a horizontal line across the lowest edge of the costal margin, and another horizontal line at the level of the iliac crest.
The names are: right and left hypochondriac, epigastric, right and left lumbar, umbilical, right and left inguinal, and hypogastric (pubic).

15. Portion of right kidney. Right adrenal gland. Epigastric:
Right hypochondriac
Right lobe of the liver.
Gallbladder.
Portion of the duodenum.
Hepatic flexure of colon.
Portion of right kidney.
Right adrenal gland.
Epigastric:
Pyloric sphincter.
Duodenum.
Pancreas.
Portion of liver.
Aorta.
Left hypochondriac:
Stomach.
Spleen.
Tail of pancreas.
Splenic sphincter of colon.
Upper pole of left kidney.
Left adrenal gland.
Right lumbar:
Ascending colon.
Lower half of Rt. Kidney.
Portion of duodenum & jejunum.
Umbilical:
Lower part of duodenum.
Jejunum and ileum.
Left lumbar:
Descending colon.
Lower half of left kidney.
Portion of jejunum & ileum.
Right inguinal:
Cecum.
Appendix.
Lower end of ileum.
Right ureter.
Right spermatic cord.
Right ovary and uterine tube.
Hypogastric:
Ileum.
Bladder.
Uterus (in pregnancy)
Left inguinal:
Sigmoid colon.
Left ureter.
Left spermatic vcord.
Left ovary and uterine tube.

16. Gathering the data: Describe your appetite? Has your weight changed?
How much coffee, tea, cola, chocolate do you eat in 24 hours?
Do you associate any food with problems such as indigestion, pain, nausea, vomiting, diarrhea, ….? …..?
Do you experience nausea or vomiting?
Do you have any difficulty chewing or swallowing your food?
Do you work with any chemical irritants?
How would you describe your stress level?
Do you have abdominal pain?

17. General Considerations: The patient should have an empty bladder.
The patient should be lying supine on the exam table and appropriately draped.
The examination room must be quiet to perform adequate auscultation and percussion.
Watch the patient's face for signs of discomfort during the examination.
Sequence of assessment techniques:
Inspection, Auscultation, Percussion, Palpation.

18. Inspection: Observe the abdominal contour: Is it: Flat. Scaphoid.
Rounded.
Protuberant.
Observe location of the umbilicus:
Normally in the center of the abdomen, inverted or protruding.
Should be clean and free of drainage or inflammation.
Observe skin of the abdomen:
Color, scars, striae, hernias (umbilical), vascular changes, lesions, or rashes.
Observe the abdomen for Symmetry, bulging, or masses:
Compare left with right sides.
A bulge could indicate a tumor, cyst, or hernia.
Observe the abdominal wall for movement:
Movement could be peristalsis or pulsations.

19. Auscultation:
Auscultation should be done prior to percussion and palpation since bowel sounds may change with manipulation.
Use the diaphragm of the stethoscope to listen for bowel sounds, and the bell to listen for vascular sounds.
Auscultate for bowel sounds:
Since bowel sounds are transmitted widely in the abdomen, auscultation of more than one quadrant is not usually necessary. If you hear them, they are present.
Begin in the RLQ over the ileo-cecal junction of the intestine:
Note the character and frequency of sounds.
Count sounds for at least 60 seconds.
Normal sounds are irregular, gurgling, and high in pitch. They occur from 5-30 times per minute.

20. Auscultation: Auscultate for vascular sounds:
Listen over the renal arteries, iliac arteries, femoral arteries, and aorta.
Bruits is a low pitched, vascular sounds, resembling murmur. It is caused by partially obstructed artery – turbulence.
A venous hum (soft, continuous, and low-pitched) in the abdomen usually indicates increased portal tension.
Auscultate for vascular sounds:
Auscultate for a friction rub:
Friction rubs are caused by two organs rubbing together or by an organ rubbing against the peritoneum.
A friction rub in the abdomen usually indicates tumor, infection, infarct, or peritonitis and requires further medical evaluation.
Friction rubs are not normally heard.

21. Percussion Abdominal sounds heard upon percussion: Tympany: Dullness:
A loud hollow sound should be obtained in the four quadrants.
They are loudest over the gastric bubble and intestines.
Dullness:
A short, high-pitched sound heard over liver, spleen, and distended bladder.
Hyperresonance:
Louder than tympany.
Heard over air-filled or distended intestines.
Flat:
A very soft, short, abrupt sound.
Heard when no air present is present in the structure, as over muscle, bone, or tumor mass.

22. Percussion
Percuss the four quadrants of the abdomen to determine the amount of tympany and dullness.
Normally you hear tympany because of the air in the underling structure.
Percussion over liver and spleen produces a dull sound.
Dullness may indicates an enlarged uterus, distended urinary bladder, or ascitis.

23. Percussion Percuss the liver: (determine liver span)
Percussion provides most accurate clinical measurement of liver size as a gross measurement.
Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness.
Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness.
Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

24. Percussion Percuss the spleen:
The spleen is located in the curve of the diaphragm just posterior to the left midaxillary line.
When the spleen enlarges, it does so anteriorly, downward and medially. This will replace the tympany of the stomach and colon with dullness.

25. Palpation General Palpation: Begin with light palpation:
At this point you are mostly looking for areas of tenderness.
The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands).
Voluntary or involuntary guarding may also be present.
Use pads of fingertips in light dipping motions and avoid short jabs.
Light Palpation

26. Palpation General Palpation: Proceed to deep palpation:
After surveying the abdomen lightly. Try to identify abdominal masses or areas of deep tenderness.
Used to define and delineate organs or abdominal masses.
If masses are felt, note: location, size, shalpe, consistency, tenderness, pulsations, mobility with respiration or with hand.
If patient is obese or rigid, use 2 hands to palpate, place one on top of other and feel with lower hand.
Deep Palpation
Deep Palpation

27. Special Tests: Shifting Dullness:
This is a test for peritoneal fluid (ascites). 
Small amounts of peritoneal fluid are not usually detectable on physical exam.

28. Special Tests: Rebound Tenderness:
This is a test for peritoneal irritation.
Rebound tenderness mean the withdrawal has caused the pain--- not the pressure.

29. Special Tests: Psoas Sign: Rovsing's sign:
This is a test for appendicitis. 
Rovsing's sign:
Tenderness felt in the RLQ when palpation is performed on the left.
It suggests appendicitis.
Rebound tenderness referred from the left to the RLQ also suggests this disorder

30. Special Tests: Murphy's sign:
While palpating the liver, ask the client to take a deep breath. The diaphragm descends, pushing the liver and gallbladder toward your fingers.
Murphy's sign is positive if the client experience sharp abdominal pain and immediately stops inspiration.
Positive Murphy's sign is usually present in client with cholecystitis.