9. Auscultation
Before palpation & percussion!
Auscultate 4 quadrants for 15 seconds for bowel sounds if you
cannot hear any sound in the first area that you auscultate
10. Bowel sounds
Normal – gurgling
Absent – ileus / peritonitis
Bruits: These are sounds produced by the turbulent fl ow of
blood through a vessel
Aortic bruits – auscultate just above the umbilicus – AAA
Renal bruits – auscultate just above the umbilicus, slightly
lateral to the midline
12. General approach
The patient should be positioned lying supine with the head supported by a single
pillow and arms at their sides.
Each of the four quadrants should be examined in turn with light and then by deep
palpation before focusing on specific organs.
The order in which they are examined doesn’t matter—find a routine that suits you.
Ask the patient if there is any area of tenderness, and remember to examine this part
last.
Before you begin, ask the patient to let you know if you cause any discomfort. You
should be able to examine the abdomen without looking at it closely.
You should watch the patient’s face for signs of pain.
13. Light palpation
Use the fingertips and palmar aspects of the fingers.
Lay your right hand on the patient’s abdomen and gently press in by
flexing at the metacarpophalangeal joints.
If there is pain on light palpation, attempt to determine whether the pain
is worse when you press down or when you release the pressure
( rebound tenderness ).
If the abdominal muscles seem tense, Ensure that the patient is
relaxed—it may be helpful for the patient to bend their knees slightly,
relaxing the abdominal muscles. An involuntary tension in the abdominal
muscles, apparently protecting the underlying organs, is called guarding
14. Light palpation
Palpate each of the 9 abdominal regions, assessing for any of the below.
Tenderness – note the areas involved and the severity of the pain
Rebound tenderness – pain is worsened on releasing the pressure – peritonitis
Guarding – involuntary tension in the abdominal muscles
Masses – large/superficial masses may be noted on light palpation
15. Deep palpation
Assess each of the 9 regions again, but with greater pressure
applied during palpation.
If any masses are identified then assess:
C C S S S L M N O P
19. Liver
1. Begin palpation in the right iliac fossa
using the flat edge of your hand (radial
side of your right index finger)
2. Press your hand into the abdomen as
you ask the patient to take a deep breath
3. Feel for a step, as the liver edge passes
below your hand
4. The normal liver extends from the 5th
intercostal space on the right of the midline
to the costal margin, hiding under the ribs
so is often not normally palpable
20. Gallbladder
The gallbladder is not usually palpable.
An enlarged gallbladder suggests obstruction to biliary
flow/infection (cholecystitis).
Perform palpation at the right costal margin, mid-
clavicular line (9th rib tip).
If enlarged, a rounded mass moving with respiration may be
palpated (note any tenderness).
21. Murphy’s sign
Place your hand in the right costal margin, at
the tip of the 9th rib mid-clavicular line
Ask the patient to take a deep breath
As the gallbladder is pushed down into your
hand the patient may suddenly develop pain
and stop inspiring.
If this occurs and there is no discomfort in the
same location on the left side of the abdomen
then this is known as a positive Murphy’s sign,
which is suggestive of cholecystitis
22. Spleen
The spleen only becomes palpable when it’s at least three
times its normal size!
1. Start in right iliac fossa – massive splenomegaly
can extend this far!
2. Align your fingers in the same direction as the left
costal margin
3. Press your right hand into the abdomen as you
ask the patient to take a deep breath
4. Feel for a step, as the splenic edge passes under
your hand (a notch may be noted)
5. If you don’t feel anything, repeat process with
your hand 1-2 cm closer to the left hypochondrium
23. Kidneys
1. Place your left hand behind the patient’s back, at
the right flank
2. Place your right hand just below the right costal
margin in the right flank
3. Press your right hand’s fingers deep into the
abdomen
4. At the same time press upwards with your left
hand
5. Ask the patient to take a deep breath
6. You may feel the lower pole of the kidney
moving inferiorly during inspiration
7. Repeat this process on the opposite side to
assess the left kidney
25. Abdominal organs
Liver : percuss up from RIF then down from right side of chest to
determine the size of the liver (liver span)
26. Spleen
percuss up from RIF moving
towards the left
hypochondrium to assess for
splenomegaly
27. Shifting dullness for ascites
1. Percuss from the center of the abdomen to the flank until dullness is noted
2. Keep your finger on the spot at which the percussion note became dull
3. Ask patient to roll onto the opposite side to which you have detected the
dullness
4. Keep the patient on their side for 30 seconds
5. Repeat your percussion in the same spot
6. If fluid was present (ascites) then the area that was previously dull should
now be resonant
7. If the flank is now resonant, percuss back to the midline, which if ascites is
present, will now be dull (i.e. the dullness has shifted)
