Examination for Ascites Wash your hands & Introduce the exam to your patient Positioning & Draping · Position so that the patient’s abdominal muscles are relaxed. Therefore, the patient: o is lying flat o has arms at their sides o has a pillow · Drape so that the abdomen is visible from the nipples to at least the Anterior Superior Iliac Spines (ASIS’s) Inspection · General -Look for: o masses, scars, and lesions (trauma) o atrophy/hypertrophy o discolouration o swelling o muscle bulk/symmetry o distended abdomen · Specific to Ascites -Look for: o bulging flanks from the foot of the bed o peripheral edema · Ascites often presents with other stigmata of liver disease. Look for: o Jaundice § look at the sclera and frenulum o Hands § palmar erythema § Dupuytren's contracture § clubbing 1 © Michael Colapinto § Terry’s nails § thenar (thumb) wasting § leukonycia § asterixis · get the patient to cock their wrists back while holding their arms out straight · look for intermittent flapping o Estrogen dependent § spider nevi § gynecomastia § frontal balding § testicular atrophy o Liver dependent § jaundice & ascites § hepatomegaly or contracted liver § splenomegaly § hemorrhoids & esophageal varices § caput medusa § easy bruising & petechiae § edema o Miscellaneous § fetor hepaticus § encephalopathy § temporal wasting Special maneuvers · Test for Shifting Dullness (see Figure 1) o percuss at the centre of the abdomen then percuss toward the patient’s right flank and mark where dullness arises o roll patient into the Right lateral decubitus position and repeat your percussion technique 2 o with ascites, the area of dullness will shift to the dependent side (ie) the area of tympany shifts toward the top Figure 1: Shifting Dullness A B © Mary Sims In this diagram, it can be seen how the fluid in the patient’s abdomen shifts as they are moved from (A) the supine position into (B) the Right lateral decubitus position. Thus, the area of dullness on percussion shifts with the position change. · Fluid wave test (see Figure 2) o get the patient to place the radial edge of their hand and their index finger in the head-to-toe direction in the centre of their abdomen o place your hands on either side of the patient o gently tap one side of the abdomen and feel for the tap on the other side 3 Figure 2: Technique for Fluid Wave Test © Mary Sims 4 .