Like all clinical examinations, examination of the abdomen begins with a general examination. This particularly involves inspection and so getting the patient in the right position to begin with is of paramount importance. The patient should be lying flat, or at least as close to flat as is possible (some patients, particularly those with heart complaints, might find lying completely flat very difficult). They should also be in a comfortable position with their hands by their side. Having introduced yourself and made sure that the patient is happy to carry on (and, of course, checking that the patient is willing for you to do what you're supposed to do!) then you can proceed with the examination.
As always, inspection requires that you take a good overall look at the patient, check they're not hooked up to any tubes or wires, and that they're looking the right colour. In fact inspection will go throughout the examination, but this is a good opportunity to get an overall impression. Does the patient look well or in pain? You can often pick up some really useful hints just by looking at the patient.
When we start looking at specific parts of the body, we begin with the hands. There's all sorts of signs which we can pick up here including many peripheral stigmata of chronic liver disease. You might also notice that a patient is anaemic if their hands are paler than you'd expect.
Having taken the pulse (just because it's a useful thing to be thinking about - and because a raised pulse can give an indication of the seriousness of the pathology) it's time to move on. Now the order can obviously vary, but in terms of keeping a smooth flow as you work your way round, it may be appropriate at this point to check for any enlarged lymph nodes in the axilla (the arm pit!) by feeling under the arm. If there are any abnormally large masses under the arm then check to see if they're tender (i.e. the patient will flinch if they hurt). Having taken into account any clues in the history, it's likely that the masses could be no big problem, but there's also the possibility that they are nodes which have been enlarged due to an illness in the abdomen.
Next it's obviously important to check the face for any signs of particular problems. The biggest and best sign which you can see in the face is jaundice. Jaundice is one of the signs which is easy to remember but can be difficult to spot. If you do spot it, then it's a huge clue as to which part of the body is causing a problem, but it's a long way away from a diagnosis. It suggests there's something wrong around the liver (although it could also relate to the spleen, or even neither of them!) and it relates to an excess of bilirubin, a waste product when blood cells are broken down.
You can also look under the eyelids for anaemia, as you would do in a cardiovascular exam.
As you move down to the neck, this is another opportunity to check for enlarged nodes. If you find any, it doesn't mean that there's an abdominal complaint - far from it! But it certainly could be related to problems in the abdomen, and it can be helpful to see if lymph nodes in the neck have been enlarged.
Finally we get to the abdomen itself. It's not difficult to work out exactly what the abdomen is, but making sure that you examine the whole thing (including the bit that starts at the ribs, and including the femoral regions) is very important - a huge number of hernias can be missed, for example, if the inguinal orrifices are not investigated. But how do you go about looking at such a big area?
The easy answer to that is by splitting the area up - and this means by splitting the area into either four or nine regions.
The four regions are quite simple: with a division down the middle and across the middle, you get the left and right upper quadrants, and the left and right lower quadrants.
If you choose to do the nine regions instead, you divide it with two vertical and two horizontal lines. The vertical boundaries marked by the mammary lines (although these work out about the midclavicular lines). The top horizontal boundary is marked by the transpyloric line, and the bottom horizontal line is the transtubercular line. This gives the epigastric, umbilical and hypogastric regions down the middle; the left and right hypochondria at the top; the left and right lumbar regions across the centre; and the left and right inguinal regions at the bottom.
In each of these regions, then, you need to palpate - to begin with, going round relatively lightly and checking that there's no obvious pain anywhere; then doing deep palpation, pressing firmly and deeply but gently with the whole of the hand to see if there are any obvious masses or if there is anything unusual to feel - and to see if there is any tenderness. It may be that the patient hasn't been aware of any pain, and when you push in it hurts, so be ready for it! And be looking at the patient's face all the while to make sure you know when there's any pain! You can start anywhere you like, but if the patient has reported pain (e.g. in the left upper quadrant) then start at the opposite side of the abdomen so they have time to get used to your palpation before you get to their painful area.
If that's all fine, you can go on to check that the liver and the spleen are normal sized. Start with the liver, and move your hand to the right inguinal region. Press your hand in firmly to see if you can feel the liver edge. Then ask the patient to take a deep breath; the liver will be pushed down onto your hand if it is enlarged. Gradually work your hand up towards the ribs on the right side to see if at any point you start feeling the liver. In a normal patient, you won't be able to.
Then do the same for the spleen; start in the right inguinal region, and cross diagonally towards the left upper quadrant until you reach the ribs. It's important to start so far away in both cases because both can be very, very enlarged - and if you report that the spleen wasn't enlarged when the patient has a spleen the side of a football then you'll look very stupid indeed!!
Don't forget to feel for an abdominal aortic aneurysm (a kind of expansile feeling in the middle of abdomen, rather than a simple pulsation which you could feel on a normal thin patient). Balloting the kidneys is also important to do, as you put one hand under the patient and the other one on top; then, by pushing alternately from either side, you can try to 'toss' the kidneys from one hand to the other. Usually you'll only feel them if they're enlarged.
Using percussion, you can determine the borders of the spleen and liver. The top of the liver is usually in 5th intercostal space, so beneath this the percussion note will be dull rather than the resonant sound of the lung. Percussion should also be used on the abdomen to see if there is any abnormal note; usually there should be some resonance with dullness around the side, but if when the patient moves to side this dullness shifts, the sign is originally names "shifting dullness" and is a sign of ascites (free fluid in the abdomen).
Finally, ausculation. This means listening for a minute or so in each area to see if there's any abnormal bowel sounds (increased, decreased, or completely absent?) and if there's any bruits (abnormal flow through an artery). If there is bowel obstruction, this might lead to 'tinkling' bowel sounds - the bowel sounds might be louder, and you can hear the sound of tinkling as liquid tinkles about in the bowel around the blockage.
It might be worth doing ausculation before palpation. Although this is usually discouraged, there may be bruits which are dangerous to palpate and which you can pick up before you stick your hand in. Palpation may also lead to bowel sounds that could cover up a bruit that's really important to catch!