image Centimeter ruler or tape measure

image Marking pen


Have patient in the supine position to start the examination. Approach the patient from the right side.

Inspect abdomen in all four quadrants (see box on p. 151)
imageSkin color/characteristics EXPECTED:Usual color variations, such as paleness or tanning lines. Fine venous network (venous return toward head above umbilicus, toward feet below umbilicus).
UNEXPECTED:Generalized color changes, such as jaundice or cyanosis. Glistening taut appearance. Bluish periumbilical discoloration, bruises, other localized discoloration. Striae, lesions or nodules, a pearl-like enlarged umbilical node, scars.

Begin seated to patient’s right to enhance shadows and contouring. Inspect while patient breathes comfortably and while patient holds a deep breath. Assess symmetry, first seated at patient’s side, then standing behind patient’s head.
EXPECTED:Flat, rounded, or scaphoid. Contralateral areas symmetric. Maximum height of convexity at umbilicus. Abdomen remains smooth and symmetric while patient holds breath.
UNEXPECTED:Umbilicus displaced upward, downward, or laterally or is inflamed, swollen, or bulging. Any distention (symmetric or asymmetric), bulges, or masses while breathing comfortably or holding breath.
imageSurface motion EXPECTED:Smooth, even motion with respiration. Females mostly costal; males mostly abdominal. Pulsations in upper midline in thin adults.
UNEXPECTED:Limited motion with respiration in adult males. Rippling movement (peristalsis) or marked pulsations.

Anatomic Correlates of the Four Quadrants of the Abdomen

Right Upper Quadrant (RUQ)

Liver and gallbladder



Head of pancreas

Right adrenal gland

Portion of right kidney

Hepatic flexure of colon

Portions of ascending and transverse colon

Right Lower Quadrant (RLQ)

Lower pole of right kidney

Cecum and appendix

Portion of ascending colon

Bladder (if distended)

Ovary and salpinx

Uterus (if enlarged)

Right spermatic cord

Right ureter

Left Upper Quadrant (LUQ)

Left lobe of liver



Body of pancreas

Left adrenal gland

Portion of left kidney

Splenic flexure of colon

Portions of transverse and descending colon

Left Lower Quadrant (LLQ)

Lower pole of left kidney

Sigmoid colon

Portion of descending colon

Bladder (if distended)

Ovary and salpinx

Uterus (if enlarged)

Left spermatic cord

Left ureter

Inspect abdominal muscles as patient raises head
  EXPECTED:No masses or protrusions.
UNEXPECTED:Masses, protrusion of the umbilicus and other hernia signs, or muscle separation.
Auscultate with stethoscope diaphragm

imageFrequency and character of bowel sounds
Warm stethoscope diaphragm, and hold with light pressure.

May auscultate at a single site because bowel sounds generalize, but auscultate in all quadrants if you have reason to be concerned.
EXPECTED:Five to 35 irregular clicks and gurgles per minute. Borborygmi, or increased sounds, due to hunger.
UNEXPECTED:Increased sounds unrelated to hunger, high-pitched tinkling sounds, or decreased or absent sounds after 5 minutes of listening (may be associated with abdominal pain and rigidity).
imageLiver and spleen EXPECTED:Silent.
UNEXPECTED:Friction rubs.
Auscultate with stethoscope bell

imageVascular sounds
Listen with stethoscope bell in epigastric region, over aorta, and over renal, iliac, and femoral arteries.
EXPECTED:No bruits, venous hum, or friction rubs.
UNEXPECTED:Bruits in aortic, renal, iliac, or femoral arteries.

From Thompson and Wilson, 1996.

imageEpigastric region and around umbilicus EXPECTED:No venous hum.
UNEXPECTED:Venous hum.

Percussion Notes of the Abdomen

Note Description Location
Tympany Musical note of higher pitch than resonance Over air-filled viscera
Hyperresonance Pitch lies between tympany and resonance Base of left lung
Resonance Sustained note of moderate pitch Over lung tissue and sometimes over abdomen
Dullness Short, high-pitched note with little resonance Over solid organs adjacent to air-filled structures

Modified from AH Robins Co.

Percuss abdomen
Note: Percussion can be done independently or concurrently with palpation.

Percuss in all quadrants.
EXPECTED:Tympany predominant. Dullness over organs and solid masses. Dullness in suprapubic area from distended bladder. See table on p. 153 for percussion notes.
UNEXPECTED:Dullness predominant.

imageLiver span
To determine lower liver border, percuss upward at right midclavicular line, as shown in figure below, and mark with a pen where tympany changes to dullness. To determine upper liver border, percuss downward at right midclavicular line from an area of resonance, and mark change to dullness. Measure the distance between marks to estimate vertical span.
EXPECTED:Lower border usually begins at or slightly below costal margin. Upper border usually begins at fifth to seventh intercostal space. Span generally ranges from 6 to 12 cm in adults.
UNEXPECTED:Lower liver border more than 2 to 3 cm below costal margin. Upper liver border above the fifth or below the seventh intercostal space. Span less than 6 cm or greater than 12 cm.

Percuss just posterior to midaxillary line on left, beginning at areas of lung resonance and moving in several directions. Percuss lowest intercostal space in left anterior axillary line before and after patient takes deep breath.
EXPECTED:Small area of dullness from sixth to tenth rib. Tympany before and after deep breath.
UNEXPECTED:Large area of dullness (check for full stomach or feces-filled intestine). Tone change from tympany to dullness with inspiration.

Percuss in area of left lower anterior rib cage and left epigastric region.
EXPECTED:Tympany of gastric air bubble (lower than intestine tympany).
Lightly palpate abdomen
Stand at patient’s right side. Systematically palpate all quadrants, avoiding areas previously identified as problem spots. With palmar surface of fingers, depress abdominal wall up to 1 cm with light, even circular motion. EXPECTED:Abdomen smooth with consistent softness. Possible tension from palpating too deeply, cold hands, or ticklishness.
UNEXPECTED:Muscular tension or resistance, tenderness, or masses. If resistance is present, place pillow under patient’s knees, and ask patient to breathe slowly through mouth. Feel for relaxation of rectus abdominis muscles on expiration. Continuing tension signals involuntary response to abdominal rigidity.
Palpate abdomen with moderate pressure
Using same hand position as above, palpate all quadrants again, this time with moderate pressure. EXPECTED:Soft, nontender
Deeply palpate abdomen
With same hand position as above, repeat palpation in all quadrants, pressing deeply and evenly into abdominal wall. Move fingers back and forth over abdominal contents. Use bimanual technique—exerting pressure with top hand and concentrating on sensation with bottom hand, as shown in figure below—if obesity or muscular resistance makes deep palpation difficult. To help determine whether masses are superficial or intraabdominal, have patient lift head from examining table to contract abdominal muscles and obscure intraabdominal masses. EXPECTED:Possible sensation of abdominal wall sliding back and forth. Possible awareness of borders of rectus abdominis muscles, aorta, and portions of colon. Possible tenderness over cecum, sigmoid colon, and aorta and in midline near xiphoid process.
UNEXPECTED:Bulges, masses, tenderness unrelated to deep palpation of cecum, sigmoid colon, aorta, xiphoid process. Note location, size, shape, consistency, tenderness, pulsation, mobility, movement (with respiration) of any masses.

imageUmbilical ring and umbilicus
Palpate umbilical ring and around umbilicus. Note whether ring is incomplete or soft in center.
EXPECTED:Umbilical ring circular and free of irregularities. Umbilicus either slightly inverted or everted.
UNEXPECTED:Bulges, nodules, granulation. Protruding umbilicus.

Place left hand under patient at eleventh and twelfth ribs, lifting to elevate liver toward abdominal wall. Place right hand on abdomen, fingers extended toward head with tips on right midclavicular line below level of liver dullness, as shown in figure at right. Alternatively, place right hand parallel to right costal margin, as shown in figure at right, below. Press right hand gently but deeply in and up. Ask patient to breathe comfortably a few times and then take a deep breath. Feel for liver edge as diaphragm pushes it down. If palpable, repeat maneuver medially and laterally to costal margin.
EXPECTED:Usually liver is not palpable. If felt, liver edge should be firm, smooth, even.
UNEXPECTED:Tenderness, nodules, or irregularity.

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