Today we saw an interesting case of ascites. A few things to remember:
History: Ask about recent weight gain and increasing abdominal girth. Also remember to ask about ankle edema. Is there a history of liver disease or risk factors for liver disease?
Inspection: Best from the foot of the bed - have a look for bulging flanks, dilated abdominal veins and umbilical hernia.
Percussion: Percuss for flank dullness, then for shifting dullness. HINT - it is easier to perform this manoeuvre when you percuss from medial to lateral, and roll the patient AWAY from you.
Fluid Wave: place the patients hand in the middle of the abdomen to block the 'adipose wave,' then flick or tap pretty sharply on one side while feeling for the wave on the contralateral side. Some of us are "tappers" while others are "flickers". It's like the Red Sox versus the Yankees. What unites us all is that we block the fluid wave, and firmly (yet politely) elicit this finding.
Other: Look for pitting edema at the ankles, and for stigmata of liver disease.
Okay...great. So what is the evidence for all this? Does it work? I heard there is something called the "Puddle Sign".... yeah.... don't do that one.
There is a good JAMA article on ascites you can read at this link, and summarized below:
Sensitive tests: Ankle swelling, increasing abdominal girth, bulging flanks, and flank dullness.
Specific tests: Fluid Wave is the best
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