What assessment technique requires the tapping of ones fingers against a clients abdomen?

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Inspection of the abdomen gives clues to the diagnosis of intra-abdominal pathology. Combined with the patient's history, inspection can often provide a preliminary diagnosis that can be confirmed by auscultation and palpation. Despite the current popularity of various noninvasive and invasive diagnostic tests, the experienced surgeon can usually make an accurate diagnosis of intra-abdominal pathology by history and physical examination. This is demonstrated by the patient with a several-day history of right upper quadrant and back pain with associated nausea, vomiting, fever, and a visible mass in the right upper quadrant. Such a patient almost certainly has acute cholecystitis with hydrops of the gallbladder. The remainder of the physical examination merely confirms this and detects additional disease. Though inspection alone never provides a clear diagnosis, it should not be overlooked.

Generalized distention of the abdomen is usually from obesity, bowel distention by gas or liquid, or ascites. Obesity can cause generalized distension by either fat in the abdominal wall or intra-abdominal fat in the omentum or viscera. Generalized abdominal distention can also be related to ascites, particularly when associated with an everted umbilicus. Distention of the upper half of the abdomen only may be due to pancreatic cyst or tumor or to acute gastric dilatation. Distention of the lower half of the abdomen may be due to pregnancy, ovarian tumor, uterine fibroids, or bladder distention. A scaphoid abdomen is due to malnutrition.

Skin abnormalities detected on inspection of the abdominal wall need to be correlated with the clinical history. Bruising should be correlated with a history of trauma to determine the possible organs injured. Cullen's and Grey Turner's signs (bluish discoloration of the umbilicus and flanks, respectively) are related to intra-abdominal and retroperitoneal bleeding, and it is believed the blood dissects along fascial planes to reach these areas. Thus, one would want to question the patient diligently for causes of such bleeding—severe pancreatitis, trauma, or ruptured ectopic pregnancy.

Striae of the abdominal wall are a result of rupture of the reticular dermis that occurs with stretching. This is seen clinically in pregnancy, obesity, ascites, abdominal carcinomatosis, and Cushing's syndrome.

Surgical scars should be examined carefully, both as to their position and their characteristics. Often patients are unsure of what kinds of surgery they have had, but the position of the incision may give the examiner a clue. Even though a transverse right lower quadrant incision suggests appendectomy, however, it in no way proves it, and one must be circumspect in making any such assumptions. The scar tells the examiner about the surgery. All scars are initially raised and red; they gradually fade to pink and by 6 months are generally flat and skin colored or gray. Wounds that heal cleanly by first intention are thin and regular, whereas those that are infected and heal by secondary intention are wider and irregular. Keloids are wide, irregular scars with abundant hypertrophic tissue outside the field of normal scarring. Keloid formation tends to recur in certain individuals and is particularly common in blacks.

Enlarged veins are seen in three clinical situations: emaciation, portal hypertension, and inferior vena cava obstruction. In emaciation there is loss of subcutaneous fat so that the normally invisible veins become prominent. These veins become more prominent in the presence of portal hypertension. In portal hypertension the umbilical vein becomes an outflow tract of the portal system and forms collaterals with the veins of the abdominal wall. This is responsible for the caput medusa that is diagnostic of portal hypertension. The direction of blood flow in these veins in portal hypertension is normal (i.e., upward in those above the umbilicus and downward in those below) as the blood is flowing from the high-pressure portal system to the low-pressure systemic system. Finally, the veins of the abdominal wall may be dilated due to obstruction of the inferior vena cava. This occurs because the abdominal wall becomes a collateral, or bypass, around the obstruction of the cava. In this situation the direction of blood flow will be reversed below the umbilicus as the blood flows from the femoral vein to the superior vena cava. Obstruction of the inferior vena cava can occur as a result of a hepatic malignancy, as an extension of hepatic vein obstruction (Budd–Chiari syndrome), as a result of thrombophlebitis, or as a result of trauma or surgical intervention.

Masses noted on inspection of the abdomen may be related to organs in that area. Thus, a mass in the right upper quadrant may represent hepatomegaly from hepatitis or hepatic tumor, a distended gallbladder from cholecystitis or pancreatic cancer, or a carcinoma in the head of the pancreas. An epigastric mass is likely to be from acute gastric distention. pancreatic pseudocyst, pancreatic cancer, or aneurysm of the abdominal aorta (which will be pulsatile). Masses in the left subcostal region are generally due to splenomegaly, although carcinoma of the spenic flexure of the colon is also a possibility.

Masses in the lumbar region are generally of renal origin. Renal cysts, polycystic kidneys, and renal malignancies may all be visible in asthenic patients.

Masses in the lower quadrants may result from inflammatory or neoplastic disorders of the intestine. In the right lower quadrant appendiceal abscess and cecal carcinoma are most likely, while in the left lower quadrant diverticular abscess or carcinoma of the sigmoid colon is most likely.

Hypogastric masses are the result of pelvic pathology. Acute urinary retention is the most common cause of such a mass in males. In females, uterine or ovarian neoplasms may cause visible midline abdominal masses.

Visible intestinal peristalsis is usually the result of intestinal obstruction. This can be seen in the stomach of the newborn with hypertrophic pyloric stenosis and in the small intestine of patients with small bowel obstruction from various etiologies.

Bowel sounds are of significance to the clinician as a marker of intra-abdominal pathology. The absence of bowel sounds may be one of the few indicators of intra-abdominal infection in patients with multiple problems and, particularly, altered mental status. In patients with generalized abdominal distention following laparotomy, bowel sounds may be the key diagnostic finding to differentiate ileus from early postoperative small bowel obstruction. Though radiographic examination of the abdomen may suggest bowel obstruction, the characteristic high-pitched bowel sounds are diagnostic for the experienced clinician.

Similarily, vascular bruits are helpful to the clinician as an indicator of underlying pathology. Thus they should be carefully searched for in patients with hypertension (renal artery stenosis), chronic abdominal pain (mesenteric arterial insufficiency), or claudication (occlusive disease of the aorta or iliac arteries). As continuous bruits are caused by arteriovenous fistulas, they should be searched for carefully in patients with penetrating abdominal trauma.

Abdominal rubs are rare, but may be found over the liver or spleen. A rub implies that the surface of the organ is irregular and usually is due to involvement by tumor, abscess, or infarction. More rarely, an inflammatory intra-abdominal mass may have an associated rub caused by irritation of the adjacent abdominal wall.

As mentioned previously, abdominal tenderness is a difficult physical finding to master. Nevertheless, it is a finding that must be mastered because it is often the only clear finding in peritonitis and may well determine therapy. The classic example of this is appendicitis. The history and laboratory findings may suggest appendicitis in a patient with abdominal pain, but the presence or absence of tenderness makes or breaks the diagnosis. As there are no laboratory studies that can either exclude or ensure the diagnosis of appendicitis, the clinician must make therapeutic decisions based on the physical finding of tenderness.

As tenderness is caused by inflammation of the parietal peritoneum, the etiology of tenderness can be related to the underlying organs. Thus, right upper quadrant tenderness may be caused by cholecystitis, ulcer disease, pancreatitis, or hepatitis. Epigastric tenderness is usually due to pancreatitis or peptic ulcer disease. Right lower quadrant tenderness may be related to appendicitis, cecal diverticulitis, or perforated carcinoma, whereas left lower quadrant tenderness is usually due to sigmoid diverticulitis. Flank tenderness is usually related to renal pathology, either pyelonephritis or perinephric abscess.

When tenderness is generalized, one must consider causes for generalized peritonitis. Acute perforated ulcer is a frequent cause and presents with characteristic "boardlike" rigidity of the abdominal wall. Other common causes include perforated diverticulitis, perforated appendicitis, and pancreatitis. Nevertheless, any process that produces generalized peritoneal irritation (chemical or infectious) will produce the same physical findings.

Abdominal masses are related to the underlying organs. Right upper quadrant masses include hepatomegaly, hydrops of the gallbladder, and carcinoma of the head of the pancreas. Epigastric masses are pancreatic (pseudocyst or carcinoma), gastric malignancies, and colon malignancies. Masses in the left upper quadrant are usually due to either splenomegaly or carcinoma of the stomach or colon. In the flanks, masses usually arise from the kidney (cyst or tumor), although occasionally from other retroperitoneal structures (lymphoma, sarcoma). Masses in the lower quadrants usually arise from the bowel. On the right side, common masses include appendiceal abscess and cecal carcinoma; on the left, diverticular abscess and sigmoid carcinoma. Central abdominal masses are often aortic aneurysms, and the pulsatile nature of the mass is diagnostic. Thus, in evaluating an abdominal mass, one must consider its location, mobility, and the presence or absence of tenderness in order to define its etiology.

The clinical significance of ascites is based largely on its etiology. This can often be determined by the history and physical examination, but paracentesis is diagnostic. Samples of peritoneal fluid should be sent to the laboratory for protein concentration, specific gravity, cell counts, and culture. Exudative ascites occurs in bacterial peritonitis, carcinomatosis, and pancreatic ascites and is associated with a protein concentration of over 3 gm/dl and a specific gravity above 1.016. Transudative ascites occurs in cirrhosis, Budd–Chiari syndrome, constrictive pericarditis, congestive heart failure, and hypoalbuminemic disorders such as the nephrotic syndrome. In these incidences the protein concentration is less than 3 gm/dl and the specific gravity less than 1.016.