Ascites
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Ascites may be present in cirrhosis, hypoalbuminaemia, infection or malignancy.
The presence of shifting dullness is highly suggestive of ascites.
Assessing for shifting dullness
It is usually not possible to formally assess for shifting dullness in young children, due to issues with co-operation. However, in older children, it may be possible.
1. Percuss from the umbilical region to the child’s left flank. If dullness is noted, this may suggest the presence of ascitic fluid in the flank.
Auscultation of the abdomen
Start by showing the child your stethoscope and demonstrate it on your own abdomen and/or on one of their toys to familiarise them with this piece of equipment.
Suggest listening to their abdomen, making sure the stethoscope diaphragm isn’t cold prior to it making contact with the child.
Auscultate over at least two positions on the abdomen to assess bowel sounds:
Normal bowel sounds: typically described as gurgling.
Tinkling bowel sounds: typically associated with bowel obstruction.
Absent bowel sounds: suggests ileus which is a disruption of the normal propulsive ability of the intestine due to a malfunction of peristalsis. Causes of ileus include electrolyte abnormalities and recent abdominal surgery. To be able to confidently state that a child has ‘absent bowel sounds’ you need to auscultate for at least 3 minutes (this is unlikely to be the case in an OSCE given the time restraints).
2. Whilst keeping your fingers over the area at which the percussion note became dull, ask the child to roll onto their right side (towards you for stability).
3. Keep the child on their right side for 30 seconds and then repeat percussion over the same area.
4. If ascites is present, the area that was previously dull should now be resonant (i.e. the dullness has shifted).
Genital examination
A genital examination is often performed routinely in infants and young children, however in older children or teenagers it should only be performed if relevant (i.e. vaginal discharge, suspicion of inguinal hernia or perineal rash).
Male genital examination
Inspect the genitals to assess penile and scrotal development and to identify any abnormalities:
Assess for penile abnormalities: hypospadias, chordee
Assess for descended tests: with one hand over the inguinal region, palpate the testicles with the other hand (record if testis descended, retractile or impalpable).
Note any scrotal swelling: hydrocele, hernia
Female genital examination
Inspect the external genitalia to identify any abnormalities:
Abnormal discharge: may be associated with pelvic inflammatory disease.
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