Abdominal exam

# Overview
The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.
The exam includes several parts:
- Setting and preparation
- Inspection
- Auscultation
- Percussion
- Palpation

## Setting and preparation
Position - patient should be supine and the bed or examination table should be flat. The patient's hands should remain at his/her sides with his/her head resting on a pillow. If the neck is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend her knees so that the soles of her feet rest on the table will also relax the abdomen.
Lighting - adjusted so that it is ideal.
Draping - patient should be exposed from the pubic symphysis below to the costal margin above - in women to just below the breasts.  Some surgeons would describe an abdominal examination being from nipples to knees.
Physicians have had concern that giving patients pain medications during acute abdominal pain may hinder diagnosis and treatment. Separate systematic reviews by the Cochrane Collaboration and the Rational Clinical Examination refute this claim.

## Inspection
The patient should be examined for: -
- masses
- scars
- lesions
- signs of trauma
- bulging flanks - best done from the foot of the bed
- jaundice/scleral icterus
- abdominal distension

### Stigmata of liver disease
- spider angiomata
- temporal wasting
- fetor hepaticus
- clubbing
- thenar wasting
- Dupuytren's contracture
- palmar erythema
- spider nevi
- testicular atrophy
- gynecomastia
- hematochezia (blood in stool)
- hematemesis - gastric bleed, esophageal varices
- caput medusae (rare) - venous distension
- ascites

## Auscultation
Auscultation is sometimes done before percussion and palpation, unlike in other examinations.  It may be performed first because vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus the bowel sounds. Additionally, it is the least likely to be painful/invasive; if the person has peritonitis and you check for rebound tenderness and then want to auscultate you may no longer have a cooperative patient.
Pre-warm the diaphragm of the stethoscope by rubbing it on the front of your shirt before beginning auscultation.  One should auscultate in all four quadrants, but there is no true compartmentalization so sounds produced in one area can generally be heard throughout the abdomen.  To conclude that bowel sounds are absent one has to listen for 5 minutes.  Growling sounds may be heard with obstruction.  Absence of sounds may be caused by peritonitis.

## Percussion
- all 9 areas
- percuss the liver from the right iliac region to right hypochondriac
- percuss for the spleen from the right iliac region to the left hypochondriac and the left iliac to the left hypochondriac.
Examination of the spleen
- Castell's sign or alternatively Traube's space

## Palpation
- All 9 areas - light then deep.
- In light palpation, note any palpable mass.
- In deep palpation, detail examination of the mass, found in light palpation, and Liver & Spleen
- Palpate the painful point at the end.
Assessing muscle tone- This is done by pressing a hand against the abdominal wall. There are 3 reactions that indicate pathology:
- guarding (muscles contract as pressure is applied)
- rigidity (rigid abdominal wall- indicates peritoneal inflammation)
- rebound (release of pressure causes pain)

## Other
- Digital rectal exam - Abdominal examination is not complete without a digital rectal exam.
- Pelvic examination only if clinically indicated.

## Special maneuvers
- Murphy's sign
- Obturator sign
- psoas sign
- rebound tenderness
- Rovsing's sign
- Cough Test
- scratch test

### Examination for ascites
- bulging flanks
- fluid wave test
- shifting dullness