Superficial Topography:

4-Quadrant system
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)

9-Region system
right hypochondrium | epigastrium | left hypochondrium
right flank | umbilical | left flank
right iliac | hypogastrium | left iliac

Shape & Volume: Flat, rounded (fullness, distension). Deformities, Masses, hernias, etc.

Surface: Pigmentation, hair, Striae, Spider nevi, Umbilicus (inverted/everted).
Scars (surgical), Linea nigra.
Collateral venous system (caput medusae).
Flow direction (away from umbilicus = normal or portal hypertension. toward umbilicus = vena cava obstruction).
Cullen's sign = periumbilical bluish color (hemoperitoneum).
Gray-Turner's sign = Bluish flanks (ecchymoses of the flanks in retroperitoneal hemorrhage).

Mobility: Respirations, pulsations (aortic aneurysm), peristaltic waves.

Symmetry

Bowel Sounds

Normal Peristalsis

Frequency = 5 per minute.
Wide range of bubbling and gurgling sounds, loud, medium and high-pitched quality.
Evaluate: Frequency, Intensity, Pitch, Location.

Hyperperistalsis

Increased frequency, rushing sounds, coincides with cramps.

Gastric Succussion splash

Air-fluid sound, when shaking the Patient: sloshing sound (obstruction).

Borborygmi

audible bowel sounds without stethoscope.

Bruits

Aortic

(Atherosclerotic aneurysm).

Renal

(unilateral or bilateral).

Femoral

(T-and-fro murmur, is Duroziez' sign -aortic regurgitation- best heard with diaphragm).

Hepatic

(vascular tumors -RUQ-, also venous hums).

Venous abdominal

Rubs

Hepatic

(neoplasm, abscesses, etc).

Splenic

(abscesses, infarction, etc).


Organs
Determine span and delineate borders.

Quadrants
RUQ, LLQ = Dullness. LUQ, RLQ = resonance.
Liver, spleen, bladder = dullness.
Stomach = tympanitic.
*very variable.

Ascites

Shifting dullness

(fluid shifts with gravity).

Fluid wave sign

(palpate or auscultate the fluid wave - ascitic wave of morgagni-).

Puddle's sign

(Patient on his/her hands and knees -dog position-, percuss the umbilical region for dullness).

Hypochondriums: percuss with the ulnar aspect of the fist to elicit pain.

Superficial Skin Reflexes: normal response = umbilical movement toward the stimulus.
Hyperesthesia (very light touch).
Consistency and temperature.

Superficial Palpation

Tenderness (elicit)

Abdominal wall

(Skin - crepitation, edema, subcutaneous fat).

Muscular wall

(resistance, tightening, spasm, diastasis recti).
Hernias (incisional, ventral, inguinal, umbilical).

Lymph nodes

Periumbilical (hard) = Sister Marie-Joseph nodule (metastasis).
Inguinal = Groove's sign.

Pulses

(aortic, femoral).

Deep Palpation

Movements

(persitaltic waves, pulsations, fetal).

Organomegalies

Liver
Gallbladder
Spleen
Kidneys
Urinary Bladder

Masses

(tumor, phlegmon, abscesses, cysts, hernia -describe characteristics-

Lymph Nodes

(Para-aortic -press against the spine-).

Thrills and Rubs

(renal, splenic, etc.)

Rebound Tenderness
Von Blumberg's sign = when sudden release of pressure causes sharp pain -peritonitis-.

Guarding sign Light touch of the abdomen causes a guarding response.

McBurney's sign = positive rebound tenderness over the LLQ -apendicitis-.

Rovsing's sign = applying pressure to the descending colon (left abdomen), may cause referred pain at the McBurney's point (RLQ) in appendicitis.

Abdomino-Jugular reflux

Abdominal compression for 45 seconds. Normal= transitory increase in jugular distension.

Hepato-Jugular reflux

Right hypochondrium compression increases jugular distension (congestive liver).

Maneuvers

a) Psoas sign = Have the Patient flex thigh against resistance (elevate the leg). Painful response in inflammation (retrocecal appendicitis).
b) Obturator sign = Lower abdominal pain elicited by flexing the thigh to a 90-degree angle and rotating it internally and externally (e.g pelvic abscesses).