Abdomen Year 1 Year 2 Year 3 Do Do Do: 1. Inspect • Percuss for shifting dullness and for fluid wave in • Assess for Murphy’s sign in patients suspected • Abdominal wall and flanks for contour, masses, patients with abdominal distention to detect of having . This is done by venous pattern and movements . palpation of the right upper quadrant with 2. Auscultate • Shifting dullness is determined by percussing steady pressure asking the patient to inhale • For presence of bowel sounds and for presence of circumfrentially on the and determining deeply. bruits if arterial insufficiency suspected (flanks, the transition points between resonance and • Assess for signs of peritonitis in appropriate femoral and mid-abdomen with bell) dullness (these spots are marked on each side). patients by assessing for rebound tenderness. 3. Percuss The patient is rolled on their side and again This is done by abruptly withdrawing the hand • along mid-clavicular line to determine span percussed as above to determine if this transition after palpation of the abdomen. Increased pain • Splenic borders in lowest intercostal space in left point has “shifted”. or wincing is indicative of peritonitis anterior axillary line at full expiration and • Fluid wave is determined by having an assistant inspiration. place the edge of their hand on the mid abdomen. Know • All four quadrants including above symphysis pubis Palpate gently at the flank with one hand while • A positive Murphy sign is pain causing an for bladder distention and costovertebral angle for quickly thumping the other flank with the other abrupt halt of inspiration with palpation of the tenderness hand. Sensing a shock wave with the palpating right upper quadrant. This is indicative of 4. Palpate hand is indicative of ascites. cholecystitis. • All four quadrants superficial first then deep using • McBurney’s point is located just below the bimanual technique midpoint of a line joining the umbilicus and the • Liver for enlargement, tenderness and consistency right anterior superior iliac spine. Tenderness at • Spleen using bimanual technique in right lateral this spot is indicative of appendicitis until decubitus rupture and generalized peritonitis supervenes • Kidneys using bimanual technique • Guarding or abdominal muscle rigidity is • Aorta caused by peritoneal inflammation Know: • Patients with tense abdominal muscles can be relaxed by supporting bent knees with a pillow. • Normal liver span at mid-clavicular line is 6-12 cm. • The spleen is typically not palpable in normal patients and in thin patients the kidneys are often palpable.

Educators-4-CARE Benchmarks 2009-10, v1 Stanford University School of Medicine