Makindo Medical Notes

Related Subjects: |OSCE Eye Exam |OSCE Ear Exam |OSCE Abdominal Exam |OSCE Ascites Exam |OSCE Testicular Exam |OSCE Inguinal Exam |OSCE Upper limb Neurology |OSCE Lower limb Neurology |OSCE Face Neurology

Introduction

• Wash your hands thoroughly before beginning the examination.
• Introduce yourself, confirm the patient’s name, date of birth, and explain that you will be examining their abdomen for ascites.
• Obtain informed consent and ensure the patient is in a private, comfortable setting.
• Explain that ascites is the accumulation of fluid in the peritoneal cavity, often associated with liver disease, heart failure, or malignancy.

Equipment Needed

• Examination gloves
• Towel or drape for patient comfort and modesty
• Optional: A stethoscope (for overall examination, though not specifically required for ascites evaluation)

Have a list of potential diagnoses. Examination is all predicated on the fact that very light gas filled bowel will always rise to the highest point and heavier fluid ascites remains at the lowest point.

Background Information

Step 1: General Inspection

• Have the patient lie supine with their abdomen fully exposed while maintaining dignity with appropriate draping.
• Inspect the abdomen for:
  • General Habitus a patient who has cachexia and swollen ascitic abdomen often means malignancy or alcoholic liver disease.
  • Observe for distension or bulging, particularly in the flanks
  • Abnormal contour (a rounded, globular appearance)
  • Visible signs of collateral venous circulation or caput medusae (in severe cases)
  • Note any skin changes, such as striae or dilated veins.

Step 2: Palpation

• Begin with light palpation of the entire abdomen to assess for tenderness and to get a general sense of the fluid distribution.
• Follow with deep palpation to detect any masses or organomegaly, being cautious to avoid discomfort.
• Palpate the flanks and lower quadrants for any resistance or fluctuation that might indicate fluid collection.

Step 3: Percussion

• Percuss the abdomen systematically: Start at the midline and work laterally to assess the quality of sound. Identify areas of dullness (suggesting the presence of fluid) versus resonance (suggestive of air-filled bowel). Note any asymmetry in the distribution of dullness.

Step 4: Shifting Dullness Test

• With the patient supine, percuss the midline of the abdomen and mark the area where dullness transitions to resonance on each side.
• Ask the patient to turn onto one side (e.g., the left lateral decubitus position) and wait about 1–2 minutes for the fluid to shift.
• Percuss the previously resonant area on the opposite side; if the dull area has shifted, this is a positive sign for ascites.

Step 5: Fluid Wave Test

• Position the patient supine with the abdominal wall exposed. Have an assistant (or use your hand) to press the lateral edge of the abdomen firmly to create a stable boundary.
• Using the ulnar border of your hand, firmly tap the midline of the abdomen. Place the edge of your other hand on the opposite flank and ask the patient not to contract their abdominal muscles.
• If a fluid wave is transmitted across the abdomen (a palpable or audible ripple), the test is positive for ascites.

Step 6: Closure

• Thank the patient for their cooperation and ensure they are comfortable. Provide a brief summary of your findings and explain any next steps or further investigations that may be needed (e.g., ultrasound).
• Assist the patient with re-dressing if necessary and ensure privacy is maintained.
• Wash your hands again and document your examination findings clearly in the patient’s notes.

Key Points for OSCE

• Follow a systematic approach: Inspection → Palpation → Percussion → Special Tests (Shifting Dullness and Fluid Wave).
• Clearly explain each step to the patient to maintain comfort and reduce anxiety.
• Ensure comparisons are made bilaterally during percussion and palpation.
• Be aware that large volumes of fluid will make the tests more pronounced.
• Document both positive and negative findings accurately.

Common Pitfalls

• Insufficient exposure of the abdomen may lead to missed findings.
• Rushing through the examination, which might result in an incomplete assessment.
• Failing to allow adequate time for fluid to shift when performing the shifting dullness test.
• Not explaining the maneuvers clearly to the patient, causing unnecessary discomfort or anxiety.

References & Further Reading

• Clinical Examination by Talley & O’Connor.
• Geeky Medics OSCE Resources
• OSCEstop – Online OSCE practice resources.