PALPATION OF ABDOMEN

I. Preparation & General Palpation

1. Patient Position: Ensure the patient is supine, comfortable, with arms by their side. Their knees should be flexed slightly to relax the abdominal muscles.

2. Examiner Position: Stand on the patient's right side.

3. Warm Hands: Ensure your hands are warm to avoid tensing the patient's abdominal muscles.

4. Observation of Patient: Observe the patient's face for signs of pain or discomfort during palpation.

5. Superficial Palpation:

   • Procedure: Use the flat of your hand, gently palpating all nine regions of the abdomen.

   • Purpose: To assess for:

     • Tenderness: Localized or generalized.

     • Muscle Guarding: Involuntary spasm of abdominal muscles, indicative of peritoneal irritation.

     • Rigidity: Board-like stiffness of abdominal muscles, a severe sign of peritonitis.

     • Temperature: Localized warmth.

     • Surface characteristics: Masses, lumps, superficial scars, or other skin abnormalities.

6. Deep Palpation:

   • Procedure: Use deeper pressure, still with the flat of your hand, covering all nine regions.

   • Purpose: To identify and characterize:

     • Deep tenderness: Localized areas of pain on deeper pressure.

     • Organomegaly: Enlarged organs (liver, spleen, kidneys, bladder).

     • Masses: Any abnormal lumps or swellings.

II. Specific Organ Palpation

A. Liver

1. Lower Border:

   • Procedure: Begin palpation in the right iliac fossa (RLQ) using the right hand, fingers pointing towards the patient's head. Ask the patient to take deep breaths. As the patient exhales, move your hand upwards towards the costal margin.

   • Observation: Note if the liver edge is felt. If so, describe:

     • Distance below Costal Margin: Measure in cm in the mid-clavicular line.

     • Consistency: Soft, firm, hard, nodular.

     • Tenderness: Present or absent.

     • Edge: Sharp, blunt, irregular.

     • Surface: Smooth, irregular, nodular.

2. Upper Border: Percuss to determine the upper border of liver dullness (typically 5th intercostal space in MCL).

3. Span: Measure the total liver span (upper to lower border in MCL) for overall size assessment.

4. Traube's Space (for Splenomegaly differentiation): Not for liver, but often assessed in context of upper quadrant masses.

B. Spleen

1. Palpation from Right Side (Right Hand Method):

   • Procedure: Begin palpation in the right iliac fossa (RLQ). Ask the patient to take deep breaths. As the patient exhales, move your hand diagonally towards the left costal margin, aiming for the tip of the spleen.

   • Observation: Note if the spleen is felt. If so, describe:

     • Distance below Costal Margin: Measure in cm.

     • Consistency: Soft, firm, hard.

     • Tenderness: Present or absent.

     • Notch: Palpable or not.

     • Edge: Rounded or sharp.

2. Palpation from Left Side (Left Hand Method): Use your left hand to support the lower ribs and palpate with your right hand.

3. Patient Position: Sometimes, palpation in the right lateral decubitus position (patient lying on right side with left knee flexed) can help bring out a subtle splenomegaly.

C. Kidneys

1. Bimanual Palpation:

   • Procedure: Place one hand (e.g., left) under the loin (flank) and the other hand (e.g., right) on the anterior abdominal wall over the kidney region. Ask the patient to take a deep breath. Try to "ballot" the kidney between your two hands.

   • Observation: Note size, shape, consistency, tenderness, and if it's ballotable. (Repeat for both kidneys).

D. Aorta

1. Procedure: Place fingers of both hands on either side of the midline in the epigastric region.

2. Observation: Assess for normal aortic pulsations. Note if there is an expansile pulsation (suggestive of an aneurysm) or any tenderness.

III. Palpation of Masses (if present)

If a mass is identified, characterize it comprehensively:

1. Site/Location: Which abdominal region?

2. Size: Measure in cm.

3. Shape: Regular, irregular, rounded, oval.

4. Surface: Smooth, nodular.

5. Consistency: Soft, firm, hard, rubbery, cystic.

6. Tenderness: Present or absent.

7. Mobility:

   • With respiration: Does it move with breathing? (Suggests attachment to liver, spleen, or diaphragm).

   • With palpation: Is it mobile or fixed?

   • From side to side, up and down.

8. Pulsatility: Is it pulsatile? Is the pulsation expansile?

9. Fluctuation/Transillumination: (If cystic suspected).

IV. Other Relevant Palpation

• Hernial Orifices: Palpate inguinal, femoral, umbilical, and incisional hernia sites. Ask the patient to cough to elicit impulses.

• Lymph Nodes: Re-check inguinal lymph nodes as part of general assessment for distal pathology.

• Suprapubic Region: Palpate for a distended bladder.