Three things should be noted:. As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability.
Bowel sounds in and of themselves do not carry great significance. That is, in the normal person who has no complaints and an otherwise normal exam, the presence or absence of bowel sounds is essentially irrelevant i. In fact, most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. However, you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal.
Bowel sounds can, however, add important supporting information in the right clinical setting. In general, inflammatory processes of the serosa i. Inflammation of the intestinal mucosa i. Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as "rushes.
This is followed by decreased sound, called "tinkles," and then silence. Alternatively, the reappearance of bowel sounds heralds the return of normal gut function following an injury. After abdominal surgery, for example, there is a period of several days when the intestines lie dormant. The appearance of bowel sounds marks the return of intestinal activity, an important phase of the patient's recovery.
Bowel sounds, then, must be interpreted within the context of the particular clinical situation. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process. After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound analogous to a murmur caused by turbulent blood flow through a vessel narrowed by atherosclerosis.
The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting e. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. Atherosclerosis distal to the aorta i. Blood flow through the aorta itself does not generate any appreciable sound.
Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation. The technique for percussion is the same as that used for the lung exam.
First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action see under lung exam.
There are two basic sounds which can be elicited:. What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin.
The spleen is smaller and is entirely protected by the ribs. To determine the size of the liver, proceed as follows:. Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally, resting in a hollow created by the left ribs.
When significantly enlarged, percussion in the left upper quadrant will produce a dull tone. Splenomegaly suggested by percussion should then be verified by palpation see below. The remainder of the normal abdomen is, for the most part, filled with the small and large intestines. Try percussing each of the four quadrants to get a sense of the normal variations in sound that are produced. These will be variably tympanitic, dull or some combination of the above, depending on whether the underlying intestines are gas or liquid filled.
Using the diaphragm of the stethoscope will allow you to hear high-pitched sounds. Normal bowel sounds are not constant, and so it is important to listen for about a minute over each quadrant. In order to conclude that bowel sounds are absent, one must listen for three to five minutes and hear nothing. Be sure to pick up the stethoscope as you move from quadrant to quadrant do not drag it across the abdomen. Remember that the thickness of the abdominal wall may affect auscultation, and so the bowel sounds of an obese person may be more difficult to hear.
Once all quadrants are auscultated with the diaphragm, use the bell to auscultate vascular sounds, bruits and friction rubs. To do this, listen over the aorta, and the iliac, femoral and renal arteries. Expected sounds include peristaltic, high-pitched, gurgling noises about every five to fifteen seconds in an irregular pattern.
They may be loud if the patient is hungry or has missed a meal. If so, begin palpation in the non-painful area. Observe the patient's face during abdominal palpation , as it is the main indicator of the intensity and location of pain.
Procedure: Superficial palpation : to assess for superficial or abdominal wall processes Deep palpation in all four quadrants : to assess intraabdominal organs potential signs of peritonitis Rebound tenderness : abrupt increase in pain when an examiner suddenly releases compression of the abdominal wall.
Caused by irritation of the receptors in parietal peritoneum Abdominal guarding : patient contraction of the abdominal wall muscles during palpation Involuntary guarding also referred to as " rigidity " : involuntary tightening of the muscles due to peritoneal inflammation and is often localized to a specific abdominal quadrant. Voluntary guarding: voluntary contraction in order to avoid pain during the examination and is often generalized over the entire abdomen.
Palpation of the liver Place the pads of your fingers over the right upper quadrant , approx. Palpate as you move towards the right upper quadrant and attempt to feel for the edge of the liver. Continue until you feel the liver or reach the costal margin. Asking the patient to take a deep breath may facilitate palpation of the liver , as the movement of the diaphragm will move the liver toward your hand.
Palpation of the spleen Place the pads of your fingers lateral to the belly button and palpate as you move towards the left upper quadrant. Repeat 10 cm below the left costal margin. Asking the patient to lie on their right side may facilitate palpation of an enlarged spleen. Palpation of the inguinal lymph nodes : see examination of the lymph nodes Abdominal tenderness may be a sign of numerous conditions see differential diagnosis of acute abdomen and differential diagnoses of abdominal pain.
Liver size Percussion Place the middle finger of your non-dominant hand against the abdominal wall. With the tip of the middle finger of your dominant hand, strike the distal interphalangeal joint 2—3 times. Start below the breast at the midclavicular line. Percuss as you move your hand downward and note the sound change as you transition from lung resonant to liver dull.
Continue until the sound changes again after the inferior margin of the liver. Liver scratch test The stethoscope is placed below the xiphoid and the midclavicular line is scratched with a fingernail. A scratch can only be distinctly heard over the liver. The liver scratch test is generally more accurate than percussion. Normal findings : : The normal craniocaudal liver size is 7—
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