Ascites

At physical exam rounds we discussed ascites and liver disease

Some key points:

Most sensitive findings (i.e. make it unlikely if not present):
1) flank dullness
2) bulging flanks
3) shifting dullness
4) peripheral edema
-history of increased girth, weight gain, ankle swelling

Most specific findings (i.e. make it likely if present)
1) fluid wave
2) shifting dullness

An approach to the examination in liver disease (besides examining the liver itself)

1) Signs of decompensated liver disease
-jaundice, scleral icterus, dark urine (high bilirubin)
-petechiae, ecchymoses (coagulopathy)
-edema (hypoalbuminemia)
-asterixis, level of consciousness (encephalopathy)

2) Signs of chronic liver disease / hyperestrogenemia signs
-nail and hand findings
-muscle wasting
-spider nevi
-gynecomastia
-testicular atrophy

3) Signs of portal hypertension
-ascites
-splenomegaly
-dilated abdominal veins (extreme of this is caput medusae)
-hemorrhoids

4) Signs suggesting the etiology of liver disease
-cardiac exam (liver + heart involved in "cardiac cirrhoisis", EtOH, hemochromatosis, amyloid, sarcoid)
-resp exam (liver + lungs involved in sarcoid, alpha-1 antitrypsin deficiency)
-CNS (liver + movement disorder in Wilson's)
Many more...

Reference:

Click here for JAMA rational clinical exam on ascites