Which abdominal quadrant do you Auscultate first?

Last updated: April 29, 2022

Summary

A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultation, percussion, and palpation. The examination begins with the patient in supine position, with the abdomen completely exposed. The skin and contour of the abdomen are inspected, followed by auscultation, percussion, and palpation of all quadrants. Depending on the findings or patient complaints, a variety of examination techniques and special maneuvers can provide additional diagnostic information.

Suggested sequence

Auscultation of the abdomen should be performed prior to percussion and palpation, as physical manipulation of the abdomen may induce a change in bowel sounds.

Palpation of the abdomen

• Purpose: to evaluate internal organs and identify any sources of pain (if present)
• Prior to palpation, ask the patient whether they have abdominal pain or tenderness. 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:
  1. Superficial palpation: to assess for superficial or abdominal wall processes
  2. 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
  3. Palpation of the liver
     • Place the pads of your fingers over the right upper quadrant, approx. 10 cm below the costal margin at the mid-clavicular line. 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.
  4. 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.
  5. 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).

Special tests

• Fluid wave test or shifting dullness for ascites
• CVA tenderness for diagnostic evaluation of the kidney and urinary tract
• Murphy sign for acute cholecystitis
• Signs of appendicitis
• Digital rectal examination: to assess for rectal bleeding, fecal impaction, colorectal cancer, and/or to evaluate the prostate

Differential diagnoses of abdominal pain

References

Which abdominal quadrant should be Auscultate first?

What is the order of abdominal auscultation?

What is the proper sequence for abdominal assessment?