The sequence of examining the abdomen changes according to the age and cooperativeness of the patient. Frequently all four types of assessments (inspection, auscultation, percussion and palpation) are performed at different times. For example, the medical practitioner may auscultate for bowel sounds following evaluation of heart and lung sounds at the beginning of the examination when the patient is quiet. Percussion usually follows lung percussion, and palpation may be done toward the end of the examination when the patient is relaxed and more trusting of the medical practitional.
For descriptive purposes the abdominal cavity is divided into four compartments or quadrants by drawing a vertical line midway from the sternum to the pubic symphysis and a horizontal line across the abdomen through the umbilicus. This method of division actually includes the pelvic cavity. Each section is designated as follows: Right upper quadrant (RUQ), Right lower quadrant (RLQ), Left upper quadrant (LUQ), Left lower quadrant (LLQ).
Percussion of the abdomen is performed in the same manner as percussion of the lungs and heart. Normally, dullness or flatness is heard on the right side at the lower costal margin because of the location of the Liver. Tympany is typically heard over the stomach on the left side and usually in the rest of the abdomen. An unusually tympanitic sound, like the beating of a tight drum, usually breathing. However, it can also denote a pathoilogic condition such as low intestinal obstruction or paralytic ileus. Lac of tympany may occur normally when the stomach is full after a meal, but in other situations it may denote the presence of fluid or solid masses.
Two types of palpation are performed, superficial and deep. In superficial palpation a doctor lightly places the hand against the skin and feels each quadrant, noting any areas of tenderness, muscle tone, and superficial lesions, such as cysts. Superficial palpation is often perceived as "tickling" by the patient. Which can interfere with its effectiveness, The nurse can avoid this problem by having the patient "help" with the palpation by placating them with statements such as, "I am trying to feel what you had for lunch". Admonishing the patient to stop laughing only draws attention to the sensation and decreases cooperation. Positioning the patient in supinated position with the legs flexed at the hips and knees helps relax the abdominal muscles.
Tenderness anywhere in the abdomen during superficial palpation is always noted. There are two types of abdominal pain:
Visceral pain is usually dull, poorly localized, and difficult for the patient to describe. Somatic pain is generally sharp, well localized and more easily described. When assessing abdominal pain, it is important to remember that the patient will often respond with an "all-or-none" reaction- either there is no pain or great pain. Therefore all aspects of the examination must be carefully considered when ruling out conditions such as appendicitis.
A special phenomenon called rebound tenderness, or Blumberg's sign, may be performed if the patient complains of abdominal pain. It is performed by pressing firmly over the part of the abdomen distal to the area of tenderness. When the pressure is suddenly released, the patient feels pain in the original area of tenderness. This response is only found when the peritoneum overlying a diseased visceral or organ is inflamed, such as in appendicitis.
Deep palpation is used for palpating organs and large blood vessels and for detecting masses and tenderness that were not discovered during superficial palpation. If the patient complains of abdominal pain, the area of the abdomen is palpated last. Normally, palpation of the mid-epigastrium causes pain as pressure is exerted over the aorta, but this should not be confused with visceral or somatic tenderness.
The doctor palpates the abdominal organs by pressing them with a free hand, which is placed on the patient's back. Palpation begins in the lower quadrants and proceeds upwards. In this way, the edge of an enlarged liver or spleen is not missed. Except for palpating the liver, successful identification of other organs, such as the spleen, kidney, and part of the colon, requires considerable practice with tutored supervision.
The lower edge of the liver is sometimes palpable in infants and young children as a superficial mass 1 to 2cm (1/2 to ¾ inch) below the right costal margin (the distance is sometimes measured in fingerbreadths). If the liver is palpable 3cm (1/4 inches) or 2 fingerbreadths below the costal margin, It is considered enlarged and this finding is referred to a physician. Normally the liver descends during inspiration as the diaphragm moves downward. This downward displacement should not be mistaken for a sign of hepatomegaly. In older children the liver frequently is not palpable, although its lower edge can be estimated by percussing dullness at the costal margin.
The spleen is palpated by feeling it between the hand placed against the back and the one palpating the left upper quadrant. The spleen is much smaller than the liver and positioned behind the fundus of the stomach. The tip of the spleen is normally felt during inspiration as it descends within the abdominal cavity. It is sometimes palpable 1 to 2 cm below the left costal margin in infants and young children. A spleen that is readily palpated more than 2cm below the right costal margin is enlarged and is always reported for further medical investigation.
Other anatomical structures that are sometimes palpable in children include the cecum, and sigmoid colon. The cecum is a soft, gas-filled mass in the right lower quadran. The sigmoid colon is left as a sausage-shaped mass that is freely movable over the pelvic brim in the left lower quadrant and is normally tender.
Although most of these structures are not routinely felt, one should be aware of their relative location and characteristics in order not to mistake them for abnormal masses. The most common palpable lower quadrant because with constipation the left colon fills with stool and gas until the ileocecal valve is reached. The the cecum becomes distended, causing pain, which may be erroneously associated with appendicitis.