1. Chapter 18
Abdomen

2. Competencies
Identify the physiological function of the abdominal organs.
Obtain the health history of a patient with an abdominal complaint.
Demonstrate the techniques of abdominal examination.
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3. Competencies
Relate abnormal physical examination findings to pathological processes.
Describe examination techniques of a patient with suspected appendicitis and ascites.
Document physical examination findings of the abdomen.

4. Anatomy and Physiology
Abdominal cavity
Peritoneum
Abdominal vasculature
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5. Anatomy and Physiology
Nine abdominal regions
Abdominal quadrants
Right upper
Left upper
Right lower
Left lower
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6. Anatomy and Physiology
Stomach
Small intestine
Large intestine
Liver
Gallbladder
Pancreas
Spleen
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7. Anatomy and Physiology
Vermiform appendix
Kidneys, ureters, and bladder
Lymph nodes

8. Health History Patient profile Age Gender
Child to young adult: appendicitis
Adult: peptic ulcers, cholecystitis, diabetes mellitus, GI cancers
Gender
Female: gallbladder disease, mittelschmerz, celiac disease
Male: GI cancers, cirrhosis, duodenal ulcers, diverticulosis

9. Common Chief Complaints
Nausea and vomiting
Diarrhea or constipation
Abdominal pain
Hoarseness
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10. Common Chief Complaints
Increased flatulence
Dysuria
Nocturia
Urinary incontinence

11. Characteristics of Chief Complaint
Quality
Quantity
Associated manifestations
Aggravating factors
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12. Characteristics of Chief Complaint
Alleviating factors
Setting
Timing

13. Past Health History Medical history Surgical history Allergies
Abdomen specific
Non-abdomen specific
Surgical history
Abdominal or urinary procedures
Allergies
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14. Past Health History Medications Communicable diseases
Injuries and accidents
Immunizations
Hepatitis A and B vaccines

15. Family Health History Malignancies of stomach, liver, pancreas, colon
Peptic ulcer disease, diabetes mellitus, irritable bowel syndrome, malabsorption syndromes

16. Social History
Alcohol use
Drug use
Travel history
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17. Social History Home and work environments
Hobbies and leisure activities
Economic status

18. Health Maintenance Activities
Sleep
Diet
Avoid foods that exacerbate abdominal distress
Exercise
Stress management
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19. Health Maintenance Activities
Use of safety devices
Health checkups
Blood chemistry and count
Liver function tests
Urinalysis
Stool guaiac
Colonoscopy

20. Differentiating Abdominal Pain
Visceral
Parietal
Referred

21. Examination of the Abdomen
Equipment
Order
Inspection
Auscultation
Percussion
Palpation

22. General Approach to Abdominal Examination
Greet patient and explain examination
Ensure room is warm, comfortable, and quiet
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23. General Approach to Abdominal Examination
Ask patient to void and save the sample (if indicated)
Drape patient to maintain privacy
Ask patient to point to tender areas

24. Inspection Contour Symmetry Rectus abdominis muscles
Pigmentation and color
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25. Inspection Scars Striae Respiratory movement Masses or nodules
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26. Inspection
Visible peristalsis
Pulsation
Umbilicus

27. Inspection: Normal Findings
Abdomen is flat or round, symmetrical
Uniform in color and pigmentation
No scars or striae present
No respiratory retractions
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28. Inspection: Normal Findings
No masses or nodules
Ripples of peristalsis may be visible
Non-exaggerated pulsation of the abdominal aorta may be present
Umbilicus is depressed

29. Auscultation Bowel sounds Vascular sounds Venous hum Friction rub
Assess all four quadrants
Listen for at least five minutes before concluding bowel sounds are absent
Vascular sounds
Venous hum
Friction rub

30. Auscultation: Normal Findings
Bowel sounds
Are heard in all quadrants
Usually are high-pitched
Occur 5 to 30 times per minute
Vascular sounds: no audible bruits
No venous hum
No friction rub

31. Auscultation: Abnormal Findings
Absent, hypoactive, or hyperactive bowel sounds
Pathophysiological indications
Absent and hypoactive bowel sounds may indicate decreased motility and possible obstruction
Hyperactive bowel sounds indicate increased motility and possible diarrhea, gastroenteritis

32. Examining Patients with Abdominal Drains or Tubes
Types: Drainage or feeding
Examine
Location of drain or tube
Condition of skin around the tube insertion site
Amount, color, consistency, odor of drainage
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33. Examining Patients with Abdominal Drains or Tubes
Examine (cont’d)
Amount of suction (mm Hg)
Type of suction (continuous, intermittent)
Amount of residual for tube feedings

34. Percussion Percuss all four quadrants
Begin in RLQ, move up to RUQ, move over to LUQ, move down to LLQ
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35. Percussion
Assess liver span, liver descent, margins of spleen, stomach, kidneys, liver, bladder
Sounds heard: tympany or dullness

36. Percussion: Normal Findings
Tympany heard over air-filled areas, such as stomach and intestines
Dullness heard over solid areas, such as liver or a distended bladder
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37. Percussion: Normal Findings
No tenderness elicited over kidneys and liver
Empty bladder is not percussable above the symphysis pubis

38. Percussion: Abnormal Findings
Dullness over areas where tympany is normally heard
May indicate a mass or tumor, pregnancy, ascites, full intestine
Liver span > 12 cm or < 6 cm
May indicate hepatomegaly or cirrhosis
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39. Percussion: Abnormal Findings
Liver descent > 2 to 3 cm
May indicate hepatomegaly or cirrhosis
Spleen dullness > 8 cm line
May indicate splenic enlargement
Costovertebral angle tenderness
May indicate pyelonephritis
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40. Percussion: Abnormal Findings
Ability to percuss a recently emptied bladder
May indicate urinary retention

41. Palpation Light vs. deep Palpate all quadrants
Never palpate over areas where bruits are auscultated
Normal findings
No tenderness
Smooth with consistent softness
No muscle guarding

42. Palpation: Abnormal Findings
Tenderness on palpation
May indicate inflammation, masses, or enlarged organs
Muscle guarding on expiration
May indicate peritonitis
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43. Palpation: Abnormal Findings
Presence of masses, bulges, or swelling
May indicate enlarged organs, cholecystitis, hepatitis, cirrhosis
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44. Palpation: Abnormal Findings
Liver is palpable below costal margin
May indicate CHF, hepatitis, cirrhosis, hepatic encephalopathy, cancer
Spleen is palpable
May indicate inflammation, CHF, cancer, cirrhosis, mononucleosis
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45. Palpation: Abnormal Findings
Kidneys are palpable
May indicate hydronephrosis, neoplasms, polycystic kidney disease
Aorta width > 4 cm
May indicate abdominal aortic aneurysm
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46. Palpation: Abnormal Findings
Able to palpate recently emptied bladder
May indicate urinary retention
Palpable inguinal lymph nodes > 1 cm in diameter or tender
May indicate systemic infections, cancer

47. Advanced Techniques Liver scratch test Assessing for ascites
Fluid wave
Murphy’s sign
Rebound tenderness
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48. Advanced Techniques Rovsing’s sign Cutaneous hypersensitivity
Iliopsoas muscle test
Obturator muscle test
Ballottement