This document provides guidance on performing a thorough abdominal examination, including inspection, palpation, percussion, auscultation, and rectal examination. The examination involves assessing the patient's general nutritional and liver disease status, systematically palpating and percussing the abdomen in different regions to check for tenderness, masses, organomegaly and ascites, and listening for bowel sounds or other abnormalities. A rectal examination evaluates the anus, prostate or cervix, and stool for signs of bleeding or infection. The goal is to detect any abnormalities that may indicate underlying gastrointestinal or other intra-abdominal diseases.

1. Abdominal Examination

2. General Examination
• Nutritional State
– Height, weight, waist circumference, BMI
– Tissue Stigmata of iron deficiency (angular cheilitis, koilonychia,
atrophic glossitis)
– B12 and Folate deficiency (Beefy raw tongue)
• Liver Disease
– Jaundice, Palmar erythema, Spider telangiectasia, hair loss,
bruise, purpura, epistaxis, digital clubbing, Low great fever
– Alcoholic liver disease: Dupuytren’s contracture, Parotic swelling

3. Regions of the Abdomen

4. Examination Sequence
• Introduction, Explanation, Informed Consent,
Privacy of Patient, Personal Hygiene
• Good light and warm surroundings
• Patient in supine position with the head but
*not the shoulders resting on 1 or 2 pillows in
order to relax the abdominal wall muscles
• Do not ask patient with severe breathlessness
to lie flat
• Sufficient exposure (xiphisternum to pubis)

5. Inspection
• Scaphoid, Flat or Distended
• Umbilicus: inverted, flat or everted
• Skin: Colour, Pigmentation and Hair distribution
• Visible veins: dilated veins, caput medusa
• Spider naevi
• Scar and stoma
• Abdominal movement whether corresponding to
respiration

6. PALPATION
1. Position the patient- arm alongside- place pillow below
knee to keep hip flexed to relax abdomen
2. Kneel down to palpate
3. Keep hand warm
4. Use volar surface of fingers – horizontally placed
5. Ask patient to show side of pain, if there’s any
6. Start palpating away from pain side
7. Palpate lightly in each region in turn, then repeat this
palpating deeply. As you palpate,watch patient’s face for
any sign of discomfort.
8. Test muscle tone by light dipping movements with your
finger.

8. 1. Tenderness
- with minimal pressure- in several areas-
generalized peritonitis
- severe pain + no tenderness on deep
palpation OR tenderness disappear when
patient is distracted – non organic pathology

9. 2. Guarding and rigidity
- voluntary guarding – palpation which cause pain may
cause patient to voluntarily contract overlying
abdominal muscle.
- involuntary guarding – if pain is due to inflammation,
parietal peritoneum pressure onto inflamed area
results in reflect contraction of the overlying muscles.
- board like rigidity – when whole peritoneal cavity is
inflamed there will be generalized peritonitis, then
anterior abdominal wall muscles will be held rigid.
Anterior abdominal wall does not moves with
respiration and breathing becomes thoracic

10. 3. Rebound tenderness
- Sensitive sign of intra-abdominal disease
- Not reliable indicator for peritoneal irritation
- Gently press hand in, then rapidly remove it
- Patient shows discomfort when hand is
released
- To cough, or gently percuss

11. • Generalized severe tenderness accompanied by
board like rigidity
- Generalized peritonitis secondary to a perforated
viscus (perforated duodenal ulcer/perforated
diverticulum)
• Localized but severe tenderness
- Localized peritonitis
-epigastrium- peptic ulcer
- right hypochondrium – cholecystitis
- right iliac fossa - appendicitis

12. 4. Palpable mass
- Whether organomegaly/separate mass
- If latter- palpable feces in constipated
patient/pathological
- Palpable feces- can be idented
- If mass/lump seems superficial-may be within anterior
abdominal wall rather than abdominal cavity
- Ask patient to tense abdomen by lifting up the head-
abdominal wall mass still palpable, whereas deep mass
is not

13. 5. Mass description
Site
Size
Surface
Shape
Consistency
Whether moving with respiration or not
Fixed/mobile
Pulsatile mass in upper abdomen
- normal aortic pulsation in thin people
- gastric/pancreatic tumor transmitting underlying
aortic pulsation
- aortic aneurysm

14. 6. Organomegaly
a) Hepatomegaly
i)Start palpating from right iliac fossa
ii)Use either radial border of your finger or finger pads. Do not dig in with
finger tips
iii)Keep hand stationary and ask patient to take a deep breath in. Try to feel for
liver edge as it moves down on inspiration.
iv)Moves up further a cm or so. Repeat (iii)
v)If liver edge is felt, workout if it is enlarged or displaced downwards
(hyperinflated lung from emphysema).
vi)Liver is dull to percuss whereas lung is resonant
vii) Locate upper border of liver by percussing over right lateral chest wall.
viii) normally, lower 3rd/4th ribs are dull to percuss
ix) Reduced area of dullness- emphysema, end-stage cirrhosis, interposition of
tranverse colon between the liver and the diaphragm
x)Measure distance below costal margin in cm.
Size,surface,edge,consitency,tender,pulsatile, audible bruit

16. b)Gallbladder
-palpable in right hypochodrium if it is swollen
-globular feel
-swollendue to obstruction in CBD/cystic duct
-with gallstone- not palpable(thickened and
contracted)

17. c) Splenomegaly
i)Start from right iliac fossa and ask patient to breat in as you
palpate posteriorly and caudally for 1-2cm. Try to detect
the spleen as it moves down againts your fingers.
ii) Move hand diagonally upwards and across the abdomen 1-
2cm at a time to the left hypochondrium
iii)Feel the costal margin along its length as the position of
spleen tip is variable
iv) If spleen tip cannot be felt,ask patient to roll over to
yourside and repeat the above manouvre
v)Palpate with right hand while using your left hand to press
forward patients left lower ribs from behind.
vi) Feel along left costal margin

20. d) Kidney ballotment
-to detect enlarged kidney
Put the right hand on the costovertebral angle
(renal angle)
Place the other hand on respective lumbar
region
Use the right hand to push the kidney
forward(ballot) and feel the kidney with the
left hand

21. PERCUSSION
• Solid/fluid filled structures- dull
• Structures containing air/gas-resonant
• Normally abdomen is resonant-air in intestine
• Percuss abdomen lighter than the chest
• To identify the area accurately, percuss from the
resonant side
• Assess each organ withboth palpation and percussion
• Kidneys are retroperitoneal- resonant due to overlying
colon
• Palpable mass arising from pelvic-dull-full bladder,
gravid uterus,pelvic tumour

22. 1. Shifting dullness
-presence of ascites
-from midline, percuss out to the flanks.note for
any change from resonant to dull. Ask patient to
turn over to opposite side. Wait for
awhile(10sec). Then percuss again. (+) if
resonant.
- Mark with pen the point resonant to dull. ask
patient to turn to same side. Repeat manouvre.
If line has moved up towards midline, then (+)

24. 2. Fluid thrill
- Assess if abdomen is tense
- Ask patient (or an assistant) to place his ulnar
edge of hand on the midline over the
abdomen.
- Place your left hand flat over left side of the
abdomen, and flick a finger/ tap the abdomen
from the right side.
- ascites(+) if ripple felt

26. AUSCULTATION
• Place diaphragm of stethoscope on the right
side of umbilicus for 2mins before concluding
anything
• Gurgling sound is normally heard every 5-
10secs
• (x) in paralytic illeus/peritonitis
• Increased frequency in intestinal obstruction

27. • Above umbilicus – aorta for bruits- turbulent
flow from atheroma/aneurysm
• 2-3cm above and lateral to umbilicus for renal
artery bruits- renal artery stenosis
• Hepatic bruits- hepatoma,alcoholic hepatitis
• Friction rub in perihepatitis
• Venous hum in upper abdomen over caput
medusa

28. • Succussion splash
-shaking a half-filled water bottle
Shake abdomen by lifting patient with both
hands under pelvis.
Audible splash- more than 4 hrs after patient
has eaten/drunk anything – pyloric stenosis

29. Rectal examination
• Explain procedure,ask permission to proceed and
offer a chaperon
• Position patient left lateral position ,buttocks
edge of the bed ,kness drawn upto chest ,heels
clear perineum
• Put on gloves,examine perianal skin(any skin
lesion,external haemorrhoids and fistulae)
• Lubricate finger with gel,place pulp of forefinger
on anal margin and ask patient take deep breathe
,push with gentel pressure into the anal canal

30. • Ask patient to squeeze your finger and note for
any weakness of sphincter contraction
• Palpate systematically arround entire rectum
,note abnormality and examine for mass
• Identify uterine cervix in women and the prostate
in man,asses size shape and consistency of
prostate and tenderness
• In women-normal retroverted uterus and normal
cervix palpable through anterior rectal wall
• Gyanecological malignancy-’frozen pelvis’ with
hard ,rigid feel to the pelvic organ due to
extensive peritoneal dx(ex.radiotherapy or
metastatic cervical or ovarian ca)

31. • Nrml prostate-smooth,firmwith median groove
and lateral lobes palpable
• BPH-palpable symetrical enlargement (not if it
confined to median lobe)
• Prostate ca- hard,irregular,asymetricall gland with
no palpable median groove
• Prostatitis/prostatic abscess-tendernes,change in
consistency of gland
• Hypogonadism-prostate abnormally small
• If rectum contain feces and in doubt about
palpable masses ,repeat examination after
patient defecated
• Slowly withdraw your finger and examine for
stool colour and the presence of blood or mucus

32. • Abnormally pale-biliary obstruction
• Pale and greasy-steatorhea
• Black and tarry-bleeding frm upper GI
• Grey/black-oral iron or bismuth therapy
• silvery-statorhea plus upper GI
bleeding(pancreatic ca)
• Fresh blood in/on stool-large bowel,rectal/anal
bleeding
• Stool mixed with pus-infective colitis/inflamatory
bowel dx
• Rice water stool-cholera

33. • Proctoscope-perform digital rectal examination
beforehand
• Examination of rectal mucosa-sigmoidoscopy
• Pt in left lateral position
• Gloved finger ,separate buttocks with forefinger and
thumb of one hand ,with other hand gently insert a
lubricated proctoscope with obturator in anal canal
and rectum in direction of umbilicus
• Remove obturator ,examine rectal mucosa under good
illumination ,noting abnormality
• Examine anal canal for fissures
• Ask pt strain down as instument slowly withdrawn to
detect rectal prolapse and the presence /severity of
heamorrhoids
• Confirm /exclude presence of haemorrhoids,anal
fissures,and rectal prolapse