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Teaching Tips
[Skill Modules >> Liver & Ascites >> Teaching Tips ]

Teaching Tips: Liver & Ascites

General Points

  • As with any physical sign, it is helpful to have the learner commit to an assessment before utilizing technology, such as radiography, ECG, or invasive monitoring.
  • Talk aloud to describe the maneuver as it is being performed.
  • To keep all participants interested, pose questions that learners can be thinking about until it is their turn to examine patients.
  • Ask the patient's permission before reviewing the sign as a group. Summarize to the patient when the exam is completed.
  • There are different way to approach the exam depending upon the level of the learner:
    • A finding may be simply demonstrated, or
    • A brief patient history may be given and the learner asked to demonstrate appropriate exam maneuvers, or
    • Demonstrate various maneuvers to detect an abnormality (e.g., ascites), and ask learners about the value (sensitivity and specificity) of each exam maneuver.
  • Historical points are fun and enhance interest in the exam.

The examination of a patient with ascites offers a wealth of teaching opportunities.

Case Example

  1. The team gathers at the bedside to hear about a new patient.
    • Presenters should be told in advance that bedside presentations are best if concise (some details, i.e., FH, Social Hx and more minor PMH can be omitted from the oral presentation).
    • Either the attending or senior resident should ask the patient if it is okay to present the case, and ask the patient to jump in and add comments or details to the history if omitted (example of teaching case).
  2. After explaining to the patient that examination for fluid in the abdomen can be done in several ways, ask if you can review the exam with the team.
    • Ask each of 4 team members to describe a maneuver for detection of ascites (this gives you an opportunity to view skills of the interns and students as they demonstrate). When finished, talk about which is most useful (sensitive and specific).

      Note: Use your own judgment as to whether to call on the senior supervising resident. We want the senior resident to be viewed by the patient as one of the supervising "in charge" team members rather than a junior trainee. One way to involve the senior resident is to ask him/her after the students and interns have answered, "Is there anything else that you want to add or show a technique you have learned?"

    • If you have the time, you could ask team members: "What other features might we look for on exam in this patient with ascites?"
      • Liver and spleen exam (may be difficult in tense ascites)
      • Skin: jaundice, spider angiomata, dilated vessels on abdominal wall (clustered in RUQ termed "caput medusa")
      • Mental status (in obtunded patient, helpful to look for "fetor hepaticus" on breath)

      (If out of time that day, move on to your next patient. Another day you can focus on other parts of the exam.)

    • In team rounds later or another day, consider review of the rational clinical exam for ascites. You could use this Web site (see evidence-based section) , or review articles in the literature or the JAMA series review of ascites (1993).
Conclusion: no single maneuver is highly sensitive and specific.

Fluid wave is the most specific (82-90%) and each of the other three maneuvers are more sensitive (flank dullness> shifting dullness> bulging flanks). Thus two maneuvers will be needed to have high sensitivity and specificity in detecting ascites.

Question: Some experienced examiners suggest that bulging flanks are helpful often when the other maneuvers are equivocal. How can you distinguish bulging flanks due to ascites from bulging due to a fat pad?

Question: Which hepatic conditions do you consider when a friction rub is detected over the liver?

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