3.1 Abdominal Examination/Findings
Key Takeaways
- Abdominal exam follows a fixed sequence — inspection, auscultation, percussion, then palpation — because palpation can transiently alter bowel sounds and invalidate auscultation findings.
- Absent bowel sounds in a distended abdomen suggest ileus or late mechanical obstruction; hyperactive high-pitched sounds suggest early obstruction or gastroenteritis.
- Rebound tenderness and involuntary guarding indicate peritoneal irritation and warrant urgent surgical evaluation, not conservative musculoskeletal care.
- Murphy sign (inspiratory arrest during deep right-upper-quadrant palpation) supports acute cholecystitis; McBurney point tenderness supports appendicitis.
- A pulsatile abdominal mass in an older patient with back pain is an abdominal aortic aneurysm until proven otherwise — a vascular emergency, not a chiropractic musculoskeletal case.
Abdominal Examination and Findings
Quick Answer: The abdominal exam proceeds in a fixed order — inspection, auscultation, percussion, palpation — because deep palpation can temporarily change bowel sounds. On NBCE Part II General Diagnosis items, link each maneuver to a specific finding: Murphy sign for cholecystitis, McBurney tenderness for appendicitis, shifting dullness for ascites, and rebound with rigidity for peritoneal irritation. A pulsatile mass, involuntary guarding, or absent bowel sounds in a distended abdomen are referral-level red flags.
Why Sequence Matters
The abdominal examination is one of the few physical exams where order is part of the diagnosis. Palpation stimulates peristalsis and can create false "hyperactive" bowel sounds if auscultation is performed afterward. Percussion before deep palpation also helps localize organ borders and fluid without the examiner already having pressed bowel loops into new positions.
| Step | Primary Question | High-Yield Abnormal Findings |
|---|---|---|
| Inspection | What is visible at rest? | Distension, visible peristalsis, scars, caput medusae, jaundice, ecchymosis (Grey Turner/Cullen in hemorrhagic pancreatitis) |
| Auscultation | What do the bowels sound like? | Absent sounds (ileus, late obstruction), hyperactive high-pitched rushes (early obstruction, gastroenteritis), bruits (renal artery stenosis, AAA) |
| Percussion | Where is gas vs. solid vs. fluid? | Generalized tympany (obstruction), shifting dullness (ascites), dullness over liver/spleen, loss of liver dullness (free air) |
| Palpation | Is there tenderness, mass, or organomegaly? | Guarding, rigidity, rebound, Murphy/McBurney signs, hepatosplenomegaly, AAA pulsatile mass |
Inspection
Begin with the patient supine, knees slightly flexed, abdomen fully exposed. Distension may be generalized (obstruction, ascites, obesity) or localized (mass, organomegaly, pregnancy). Visible peristalsis — waves moving across the abdomen — classically suggests high-grade small-bowel obstruction. Caput medusae (dilated periumbilical veins) and spider angiomata point toward portal hypertension and chronic liver disease, not a primary musculoskeletal complaint.
Scars tell a surgical story: midline laparotomy, right lower quadrant appendectomy, cholecystectomy subcostal scar. Jaundice visible in the sclera or skin shifts the differential toward hepatobiliary disease (cholestasis, hepatitis, hemolysis) and should trigger questions about dark urine, pale stools, and right-upper-quadrant pain.
Auscultation
Use the diaphragm; listen in all four quadrants before labeling sounds "absent." Normal bowel sounds occur roughly 5–30 times per minute — irregular and gurgling is normal; complete silence for a full minute in a quadrant is not.
| Auscultation Pattern | Typical Clinical Context | Board Trap |
|---|---|---|
| Normal | Irregular gurgles 5–30/min | Do not call "absent" after only a few seconds of listening |
| Hyperactive, high-pitched, rushing | Early mechanical obstruction, severe gastroenteritis | Hyperactive does not mean "healthy" — it often precedes silence in obstruction |
| Absent | Ileus (post-op, electrolyte disturbance, peritonitis), late obstruction | Absent sounds + distension = surgical abdomen until proven otherwise |
| Bruit | Renal artery stenosis, AAA, hepatic/portal flow abnormalities | A systolic bruit over the epigastrium or flanks is vascular, not bowel |
Clinical trap: Candidates confuse early mechanical obstruction (hyperactive sounds as the bowel fights the blockage) with late obstruction or ileus (silent abdomen). The vignette's timing — hours of cramping pain with loud sounds vs. progressive distension with vomiting and then quiet — is the discriminator.
Percussion
Percussion maps air, fluid, and solid without relying on palpation depth. Generalized tympany suggests intraluminal gas (obstruction, aerophagia). Shifting dullness — dull when the patient is supine that shifts when rolled to the side — supports ascites (typically >500 mL). Percuss the liver span in the right midclavicular line (normal roughly 6–12 cm in many adults; interpret with body habitus). Loss of hepatic dullness at the right costal margin can indicate free intraperitoneal air (perforated viscus), especially with board vignettes pairing sudden severe pain and board-like rigidity.
Splenomegaly is often detected by percussion (Traube space dullness) before it is palpable below the left costal margin — a favorite Part II pairing.
Palpation
Use light palpation first, then deep palpation, then organ-specific maneuvers. Distinguish:
- Voluntary guarding — patient tightens voluntarily; often decreases with reassurance or slow pressure.
- Involuntary guarding / rigidity — board-like, not under conscious control; indicates peritoneal irritation.
- Rebound tenderness — pain worse when pressure is released; confirms peritoneal inflammation.
| Maneuver | Technique | Positive Suggests |
|---|---|---|
| Murphy sign | Deep RUQ palpation during deep inspiration | Acute cholecystitis (gallbladder impinges on examiner's fingers) |
| McBurney point | Maximal tenderness one-third from ASIS to umbilicus on right | Acute appendicitis |
| Rovsing sign | Left lower quadrant palpation causes right lower quadrant pain | Appendicitis (peritoneal irritation) |
| Psoas sign | Pain with passive right hip extension | Retrocecal appendicitis or psoas abscess |
| Obturator sign | Pain with internal rotation of flexed right hip | Pelvic appendicitis or pelvic abscess |
| Carnett sign | Focal tenderness worsens when patient tenses abdominal wall (head lift) | Abdominal wall pain (less likely visceral surgical abdomen) |
Organ and vascular red flags: A pulsatile epigastric or periumbilical mass in an older patient — especially with back or flank pain — is treated as abdominal aortic aneurysm (AAA) until imaging excludes it. This is one of the highest-stakes traps on Part II: the patient may present with "back pain" while the life-threatening finding is abdominal.
Integrating Findings on the Exam
Part II vignettes rarely test isolated maneuvers; they test pattern recognition. Three classic clusters:
- RUQ pain, fever, Murphy sign, leukocytosis → cholecystitis; ultrasound is the next step, not spinal manipulation.
- Periumbilical pain migrating to RLQ, McBurney tenderness, anorexia, low-grade fever → appendicitis; rebound and rigidity increase urgency.
- Distension, vomiting, hyperactive then absent sounds, tympanic abdomen → small-bowel obstruction; look for hernia, adhesions, malignancy history.
When abdominal findings suggest visceral pathology, the chiropractic role is recognition and appropriate referral, not differentiation of every surgical subtype. Document objective findings (location of tenderness, presence of rebound, bowel-sound description) and escalate when peritoneal signs, pulsatile mass, or progressive distension appear.
Quick Reference: Surgical Abdomen Clues
| Finding Cluster | Think First |
|---|---|
| Rebound + rigidity + fever | Peritonitis (appendicitis, perforation, diverticulitis) |
| RUQ pain + jaundice + dark urine | Choledocholithiasis or hepatitis |
| Painless GI bleeding + hypotension | Upper GI bleed (ulcer, varices) |
| Sudden tearing back/abdominal pain + pulsatile mass | Ruptured or expanding AAA |
| Distension + absent bowel sounds | Ileus or late obstruction |
A patient with 12 hours of cramping periumbilical pain now has a distended abdomen with frequent high-pitched rushing bowel sounds in all quadrants. Which interpretation best fits this auscultation finding?
During abdominal examination, deep palpation is performed before auscultation. Bowel sounds are then described as increased. What is the most accurate conclusion about this finding?
A 68-year-old man reports mild low back pain. Supine inspection reveals a pulsatile periumbilical mass. He is normotensive today. What is the priority concern?
Right upper quadrant deep palpation during inspiration causes the patient to stop inhaling abruptly due to pain. Which diagnosis does this Murphy sign pattern most strongly support?