Internal Diseases · MU Sofia

Practical · 19. Physical methods of examination of the abdomen

Walks through the physical examination of the abdomen in the order inspection, auscultation, palpation and percussion, with patient positioning and preparation first. It covers what to look for on inspection, organ-specific palpation for liver, spleen, kidneys, aorta and bladder, and named signs such as Murphy's, McBurney's, Rovsing's and Cullen's. Percussion techniques for liver span, splenic size and ascites are included, along with normal and abnormal bowel sounds and vascular bruits.

Inside: 7 sections · 10 labelled pictures · 12 flashcards · 3 min

Topic 76 of 88 in the MU Sofia syllabus for Internal Diseases (Dental Medicine, Year 4). The free AceMed note covers it in 7 sections, about 416 words (3 min of reading), with 12 flashcards.

In this note

  1. Physical Methods of Examination of the Abdomen
  2. I. Preparation Before Examination
  3. II. Sequence of Abdominal Examination
  4. Inspection
  5. Palpation
  6. Percussion
  7. Auscultation

I. Preparation Before Examination

  • The patient should be lying supine, with arms by their sides (not above the head).
  • Abdomen should be fully exposed from the xiphoid process to the pubic symphysis.
  • Ensure adequate lighting and a warm stethoscope.
  • Ask the patient to empty the bladder beforehand.
  • Examiner stands on the right side of the patient.

II. Sequence of Abdominal Examination

Always follow the IPPA approach:

Inspection → Palpation → Percussion → Auscultation

(Note: In most systems, auscultation comes after palpation, but in abdomen we auscultate before palpation to avoid altering bowel sounds.)

Inspection

Observe the entire abdominal surface for:

General Shape:

  • Flat / Scaphoid / Distended / Protuberant / Asymmetrical

Skin:

  • Scars, striae (stretch marks), dilated veins (e.g., caput medusae in portal hypertension)
  • Discoloration (e.g., Cullen’s sign – periumbilical ecchymosis)

Movements:

  • Abdominal wall movement with respiration
  • Visible peristalsis (suggests obstruction)
  • Pulsations (e.g., aortic aneurysm)

Umbilicus:

  • Position (midline), shape, any hernia or discharge

Palpation

Performed with warm hands, gently. Begin away from the painful area.

Superficial Palpation:

  • Detect tenderness, muscle resistance, superficial masses, and skin temperature.
  • Note guarding (voluntary or involuntary rigidity).

Deep Palpation:

  • Used to detect deep masses, organ enlargement (e.g., liver, spleen, kidneys).
  • Use two-handed technique in obese patients.

Palpation of Specific Organs:

  • Liver:
  • Felt in right upper quadrant; normally not palpable or just at costal margin.
  • Enlarged liver moves with respiration.
  • Spleen:
  • Normally not palpable.
  • Enlarged spleen emerges diagonally from LUQ to umbilicus.
  • Kidneys:
  • Bimanual palpation required.
  • Ballotable in thin individuals or if enlarged (hydronephrosis, tumor, PKD).
  • Aorta:
  • Palpate midline above umbilicus for pulsation width → assess for aneurysm.
  • Bladder:
  • Palpable above pubis if distended.
  • Special signs:
  • Murphy’s sign: Inspiratory arrest on deep palpation of RUQ → cholecystitis.
  • McBurney’s point tenderness: Appendicitis.
  • Rebound tenderness: Peritoneal irritation.
  • Rovsing’s sign: Pain in RLQ when LLQ is pressed (appendicitis).
  • Psoas sign, Obturator sign: Retrocecal or pelvic appendix.

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