Abdominal assessment

Look

• Position the patient comfortably, so the abdomen is relaxed. Supine with an exposed abdomen is best.
• Maintain privacy and dignity.
• Look at all four quadrants for:
  • skin discolouration
  • scars
  • masses
  • prominent veins
  • tension, rigid or soft
  • distension (contour)
  • bruising
  • devices
  • pulsations
  • foetal movement.
• Look at the patient's movements, position and level of comfort.

Listen

• Listen for bowel sounds:
  • hyperactive – increased gastrointestinal activity, such as diarrhoea
  • reduced – decreased intestinal activity, such as an early obstruction
  • absent over four quadrants – bowel sounds absent over 4 minutes may indicate an obstruction.

Feel

• With finger pads, palpate the area of least pain first.
• Palpation is best performed when the patient's attention is diverted away from the examination, e.g. use distraction techniques.
• Start with light palpation, followed by deep palpation and then organ palpation, if within scope.
• Note the level of pressure it takes for a pain response.
• Palpate each region for:
  • tenderness
  • pain (if present, is it referred, focal or generalised)
  • guarding
  • rebound tenderness
  • masses
  • pulses.
• Palpate the bladder. A full bladder:
  • is a pelvic mass that is typically regular, smooth, firm, and oval-shaped
  • arises in the midline
  • lower border cannot be felt
  • upper border may reach as high as the umbilicus
  • palpation typically worsens the urge to urinate.
• Watch the patient walk. Being unable to walk may indicate severe abdominal pathology.

Pain location

Pain location	May indicate
Referred right scapula (shoulder tip)	gallbladder or liver disease
Referred left scapula (shoulder tip)	cardiac, gastrointestinal tract, pancreatic or splenic disease
Referred scrotal or testicular	renal colic or testicular torsion
Epigastric	gastric ulcer (long-term) pancreatitis gastrointestinal (GI) bleed cholelithiasis acute myocardial infarction (AMI)
Right upper quadrant (RUQ)	cholelithiasis cholecystitis pancreatitis hepatitis pyelonephritis renal colic organ perforation or rupture appendicitis (in pregnancy) atypical AMI
Left upper quadrant (LUQ)	splenic injury or infarction, pyelonephritis or renal colic
Left lower quadrant (LLQ) and right lower quadrant (RLQ)	diverticulitis gynaecological issues, e.g. ovarian torsion, cyst, pelvic inflammatory disease (PID) or ectopic pregnancy Crohn's disease ulcerative colitis renal colic adhesions appendicitis (RLQ) malignancy hernia

Testicular exam

• Suspected testicular torsion requires urgent escalation of care.
• Testicular torsion can present as abdominal pain. Inspect the testis and, if there is any concern for a torsion, escalate as per local CERS protocol.
• Complete testicular exam:
  • Explain the reason for the examination and what it will involve.
  • Gain consent and confirm if the patient understands the examination.
  • Involve a chaperone.
  • Allow the patient privacy to remove their underwear and provide a sheet to cover themselves.
  • Position supine.
  • Inspect the penis, testicles and around the groin for bruising, swelling, erythema, lesions or scars.
  • Move the penis and carefully check the scrotum, looking for skin changes, scars, masses, swelling, erythema or bruising.
  • If there is unilateral pain, palpate the non-painful testicle first.
  • Use your thumb and index finger to palpate the whole body of the testicle, feeling for a mass and pain.
• Typical clinical findings for a testicular torsion may include:
  • sudden onset of pain that may radiate to the right iliac fossa or thigh
  • pain that is generally localised to the upper pole of the testis and tender on palpation
  • a palpable mass in the area of maximal tenderness
  • the testis 'high riding' in the neck of the scrotum
  • red or blue discolouration
  • nausea and/or vomiting
  • blue dot sign, i.e. a tender nodule with blue discolouration on the upper pole of the testis.