🫗 Key Principle: Gas-filled bowel floats up, fluid sinks to dependent areas. So ascites reveals itself by shifting dullness and fluid thrill. 📌 Always suggest differentials + investigations → LFTs, albumin, U&Es, abdominal ultrasound, ascitic tap if safe.

👋 Introduction

🧼 Hand Hygiene: Wash hands before starting.
🙂 Introduction: Greet patient, confirm name & DOB, explain you will examine for fluid in abdomen.
📝 Consent & Privacy: Obtain consent, ensure dignity with drapes and lighting.
📖 Explain: Ascites = fluid in peritoneal cavity, common causes include cirrhosis, right heart failure, malignancy, TB.

🧰 Equipment Needed

Gloves
Towel/drape
Optional stethoscope (for broader abdominal exam)

📚 Background: Common Causes of Ascites

Cause	Mechanism	Key Clinical Features
🍺 Cirrhosis	Portal hypertension + hypoalbuminemia	Shifting dullness, spider naevi, palmar erythema
❤️ Right Heart Failure	↑ Venous pressure → transudation	Raised JVP, oedema, hepatomegaly
🎗️ Malignancy	Peritoneal carcinomatosis → protein loss	Weight loss, pain, cancer history
🦠 TB Peritonitis	Inflammatory exudate	Fever, sweats, diffuse tenderness
🔥 Pancreatitis	Leak of enzymes causing inflammation	Acute pain, nausea, ↑ amylase/lipase
🩸 Budd–Chiari	Hepatic vein outflow obstruction	Rapid ascites, RUQ pain, tender hepatomegaly
💧 Nephrotic Syndrome	Hypoalbuminemia → ↓ oncotic pressure	Anasarca, proteinuria, hyperlipidaemia

🪜 Examination Steps

👀 Step 1: Inspection
- Patient supine, abdomen exposed with dignity.
- Look for distension (flank bulging, globular contour).
- Cachexia + ascites = think malignancy or cirrhosis.
- Caput medusae = portal hypertension.
- Striae, scars, dilated veins → clues to underlying cause.
🤲 Step 2: Palpation
- Light palpation → tenderness, masses.
- Deep palpation → hepatomegaly/splenomegaly.
- Feel flanks for resistance/fluctuation.
🥁 Step 3: Percussion
- Percuss midline → resonance, move laterally → dullness.
- Dullness at flanks, resonance centrally = fluid distribution.
↔️ Step 4: Shifting Dullness
- Mark resonance/dullness borders supine.
- Roll patient to side, wait 1–2 min.
- If dullness shifts → positive for ascites.
🌊 Step 5: Fluid Wave
- Assistant/hand on midline to dampen skin wave.
- Tap one flank, feel wave on other.
- Positive = large ascites (>1–2L usually).

✅ Closure

Thank patient, redress, ensure comfort.
Summarise: “Findings suggest possible ascites - we’d confirm with ultrasound.”
Wash hands, document findings accurately.

⭐ Key OSCE Points

Systematic: Inspection → Palpation → Percussion → Shifting Dullness → Fluid Wave.
Explain each step to patient → builds rapport.
Allow time for fluid to shift → don’t rush.
Always mention investigations (USS, ascitic tap with SAAG if safe).

🚫 Common Pitfalls

Inadequate exposure → miss subtle signs.
Rushing → false negatives.
Not comparing both flanks systematically.
Forgetting to correlate with signs of CLD or systemic disease.

📚 References

Clinical Examination – Talley & O’Connor
Geeky Medics OSCE Guide
OSCEstop – Online practice bank

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OSCE Ascites Examination