GI 7 - Examine for ascites Flashcards
Inspects and comments on findings: distended, full flanks, everted umbilicus, etc.
I’m going to begin by observing the general appearance of my patient lying quietly. (Standing on the right of the patient; you should be bending down so that you can view the abdomen tangentially) I will be inspecting the surface contours, and movements of my patient’s abdomen, looking for bulges or peristalsis.
My patient’s abdomen appears* (say what you see- symmetric, flat, rounded, protuberant, or scaphoid-markedly concave or hollow).* There is no visible peristalsis (normally peristalsis is visible in very thin people). Visible peristalsis could suggest intestinal obstruction. (Color) I’m noting no bruises, erythema, or jaundice. No scars are visible which could be due to any trauma or past surgeries. I’m noting no striae (stretch marks). Abnormally colored striae (pink-purple) are a hallmark of Cushing syndrome. I’m also noting no signs of engorged veins (a few small veins may be visible normally).
Visibly engorged veins could suggest portal hypertension from cirrhosis (caput medusa) or inferior vena cava obstruction. Also, the umbilicus doesn’t appear everted. An everted umbilicus suggests a ventral hernia. There appears to be no bulging of the flanks (full flanks are present). If bulging of the flanks were present this could suggest ascites.”
Explains procedure to patient, positions and drapes (re-drapes as needed).
“Today I am going to examine your tummy area for ascites which would be seen in liver disease. This is going to involve me looking at and touching your stomach. If at any point you feel uncomfortable or are in any pain, please let me know.”
Percusses for dullness in flanks and comments on findings
“Next, I’m going to assess for ascites by percussing for any dullness. Are you in any pain? I’m going to start at the umbilicus, percussing laterally until I hear dullness. I did not hear tympany (gas or air filled) throughout the abdomen and dullness (fluid/organ) when I got to the flanks/sides.”
Asses for shifting dullness and comments on findings
“I’m also going assess for shifting dullness starting from the umbilicus again, percussing laterally until I hear dullness. Can you place your finger hear (at the lateral point) for me and roll to the right side?”
“I had the patient roll to the dependent side. If my patient had ascites, the fluid from the patient’s nondependent side (L) will shift to the patient’s dependent side (R).”
“Now, I’m going to percuss from the bottom up to the previous mark. The place that I began hearing dullness did not shift so my patient is negative for ascites. Increasing dullness is a sign of ascites. In a patient with ascites, dullness shifts down and tympany shifts to the top.”
Ascites are (free fluid in the abdominal cavity), percuss midline away from the flank (notices changes from resonant to dull). If a resonant to dull is heard upon percussion, examine for shitting dullness. KEEP the finger on the side of dullness in the flank and ask the patient to roll towards you on their side. Wait at least 10 seconds to allow any free fluid to move under the influence of gravity, then percuss again in same direction. If the area is now resonant, you have demonstrated shifting dullness as ascitic fluid become dependent.
Checks for fluid wave and comments on findings
“Now, I’m going to check for fluid wave. Can you put both hands together and press both hands firmly down the midline of the abdomen (This is to stop transmission of a wave through fat)? I’m going to be pushing on each side of the abdomen. Ok relax. I do not feel any fluid wave transmitted to either side, so my patient is negative for ascites.”
“Ascites would be cause by liver cirrhosis or nephrotic syndrome.”
“I’m going to hold the side of the flanks and tap sharply on the opposite flank with my fingertips (for an impulse transmitted through the fluid). The test is negative unless ascites is obvious.”
Fluid thrill seen in generalized ascites, to elicit this method–>
Flick a finger of right hand against the right side of the abdomen and whilst feeling the ripple against the left palm of the other side.
