A protuberant abdomen with bulging flanks suggests the possibility of ascitic fluid. Because ascitic fluid characteristically sinks with gravity, while gas-filled loops of bowel float to the top, percussion gives a dull note in dependent areas of the abdomen. Look for such a pattern by percussing outward in several directions from the central area of tympany. Map the border between tympany and dullness.
Two further techniques help to confirm the presence of ascites, although both signs may be misleading.
■ Test for shifting dullness. After mapping the borders of tympany and dull- In ascites, dullness shifts to the ness, ask the patient to turn onto one side. Percuss and mark the borders more dependent side, while tym-again. In a person without ascites, the borders between tympany and dull- pany shifts to the top. ness usually stay relatively constant.
■ Test for a fluid wave. Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. This pressure helps to stop the transmission of a wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. Unfortunately, this sign is often negative until ascites is obvious, and it is sometimes positive in people without ascites.
An easily palpable impulse suggests ascites.
Identifying an Organ or a Mass in an Ascitic Abdomen. Try to ballotte the organ or mass, exemplified here by an enlarged liver. Straighten and stiffen the fingers of one hand together, place them on the abdominal surface, and make a brief jabbing movement directly toward the anticipated structure. This quick movement often displaces the fluid so that your fingertips can briefly touch the surface of the structure through the abdominal wall.
■ Ask the patient to point to where the pain began and where it is now. Ask the patient to cough. Determine whether and where pain results.
■ Search carefully for an area of local tenderness.
■ Feel for muscular rigidity.
■ Perform a rectal examination and, in women, a pelvic examination. These maneuvers may not help you to discriminate well between a normal and an inflamed appendix, but they may help to identify an inflamed appendix atypically located within the pelvic cavity. They may also suggest other causes of the abdominal pain.
The pain of appendicitis classically begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it. Elderly patients report this pattern less frequently than younger ones.
Localized tenderness anywhere in the right lower quadrant, even in the right flank, may indicate appendicitis.
Early voluntary guarding may be replaced by involuntary muscular rigidity.
Right-sided rectal tenderness may be caused by, for example, inflamed adnexa or an inflamed seminal vesicle, as well as by an inflamed appendix.
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