Exam Checklist
- Student observes proper patient draping
- Student inspects abdomen
- Student auscultates the abdomen (before percussion or palpation) for bowel sounds and bruits
- Student palpates lightly in all four quadrants
- Student palpates deeply in all four quadrants
- Student percusses abdomen in at least four areas
- Student percusses liver and spleen
- Student palpates and measures the liver (NOT using the scratch test)
- Student palpates the spleen
- Student palpates aorta
Write-up Examples
- Abdomen is protuberant with active bowel sounds. It is soft and nontender; no masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.
- Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with increased tenderness, guarding, and rebound in the right midquadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No CVA tenderness.
Notes
- Assessment for peritoneal inflammation should be included as indicated: psoas sign, obturator sign, Murphy’s sign
- Note that initially you may use sentences to describe the findings; later you will use phrases appropriate for most write-ups. Remember to only use approved medical abbreviations.