a. Inspection. A protuberant abdomen from obesity is uniformly rounded, with the umbilicus buried. An everted umbilicus indicates increased intra-abdominal pressure. Distention from ascites is most marked in the hypogastric area when upright; flanks bulge when supine. When ascites is severe, skin is shiny, with prominent veins. Distention caused by abdominal masses may be asymmetric. Diastasis rectus (midline protrusion from xiphoid to umbilicus) is a normal variant.
b. Auscultation. Bowel sounds are high pitched in early obstruction, diminished with adynamic ileus and peritonitis.
c. Percussion. Differentiate air (tympany) from fluid and solid structures (dull). Free intra-abdominal air causes loss of normal dullness on percussion of the liver. Free fluid produces shifting dullness, percussible in the flanks when patient is supine and moving to dependent side when in lateral decubitus position.
d. Palpation. Abdomen may be rigid from peritonitis or tense from ascites. Note location, size, consistency, and movability of masses (retroperitoneal masses do not move with respiration). Stool can often be identified by its deformability. A fluid wave from ascites is demonstrated by tapping the flank with the right hand and receiving an impulse with the left hand on the opposite flank while an assistant presses downward along the midline.
4. Rectal exam. Check for imperforate anus and fecal impaction. Tenderness may imply peritonitis. Functional obstruction from Hirschsprung disease may be explosively decompressed.
5. Hernias. Assess groin and umbilicus.
6. Intake and output. Check for fluid retention or dehydration.
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