A simple bedside manoeuvre to detect ascites.

BACKGROUND: Shifting dullness and fluid wave are two techniques commonly used to detect ascites. However, these may fail to detect moderate or minimal ascites. Ultrasonography is a good non-invasive method to detect ascites but may not be available in distant rural areas of India. We assessed the utility of the puddle sign and auscultatory percussion for detecting ascites. METHODS: Sixty-six patients with suspected ascites were included in the study. Those with a previous history of ascites, or therapeutic paracentesis and in whom ascites was detected by shifting dullness or fluid wave were excluded. The puddle sign and auscultatory percussion were elicited in all the patients. Ultrasonography was used as the gold standard. To eliminate any observer bias the investigators were blinded to each others' findings. RESULTS: Auscultatory percussion had a greater sensitivity (65.7% v. 45%, p < 0.05) but a lower specificity than the puddle sign (48.4% v. 67.7%, p < 0.05). There were no significant differences between positive and negative predictive values and the positive and negative likelihood ratios. CONCLUSION: Auscultatory percussion is a better method than puddle sign for detecting ascites as it has a greater sensitivity.

Acute isoniazid poisoning: presenting as seizure.

A case of young female who was brought in status epilepticus with history of isoniazid poisoning is discussed. Early institution of treatment with pyridoxine saves the patient's life.

Accuracy of palpation and percussion manoeuvres in the diagnosis of splenomegaly.

A study was conducted on 80 patients admitted in a teaching hospital to see the accuracy of two palpatory methods (Supine palpation and Middleton's manoeuvre) and three percussion methods (Traube's space percussion, Castell's and Nixon's manoeuvres) in the diagnosis of splenomegaly. Ultrasonographic findings were considered as gold standard for diagnosing splenomegaly. Mean age of study subjects was 31.5 years and mean Quetelet's index was 17.8 +/- 2.6 kg/m2. Sensitivity of Middleton's and Castell's manoeuvres was similar (85.7%) and higher than other manoeuvres. Nixon's manoeuvre had the least sensitivity (66.7%). Specificity was highest (92.1%) with supine palpation and least (31.6%) with Castell's manoeuvre. Supine palpation showed highest positive predictive value (91.7%). Receiver Operating Characteristics curves showed greater area with middleton's manoeuvre (0.93) followed by supine palpation (0.92), Castell's manoeuvre (0.75) and Traube's space percussion (0.74), the findings of the study suggests that palpatory methods like Middeton's manoeuvre and Supine palpation should be routinely used for diagnosing splenomegaly among non-obese individuals.

Accuracy of clinical manoeuvres in detection of minimal ascites.

A study was conducted to assess the clinical accuracy of various clinical manoeuvres and signs used routinely for detection of ascites. Sixty-six patients admitted in medical ward of a teaching hospital after initial screening by a consultant were selected. Exclusion criteria were; cases with previous history of ascites, who had undergone paracentesis in the recent past or with evidence of ascites from history. Another clinician blind to history and clinical details assessed the presence of ascites by the selected methods a sonographer blind of clinical and historical details assessed the cases for presence of ascitic fluid. The clinical findings were compared using ultrasonographic (USG) findings as gold standard. Ascites was detected in 35 patients by USG. the mean weight and abdominal girth of study subjects with or without ascites were comparable (p > 0.05). Sensitivity of auscultatory percussion was highest (65.7%) followed by flank dullness (57.1%) and least for fluid wave sign (20.0%). Fluid wave sign had the highest specificity (100%). We found that none of the manoeuvres studied for detection of ascites was both highly sensitive and specific. However, auscultatory percussion could be useful for initial screening of patients to detect ascites.

Interobserver variations in clinical signs for diagnosis of pleuritis.

A study was conducted on 150 patients admitted in a teaching hospital to find out reliable clinical signs for diagnosing pleuritis. Cases were selected based on suspicion of pleural involvement by history and examination. Final diagnosis was made by correlations with radiographic and ultrasonographic reports. Reliability of the signs was determined on the basis of high concordance of independently observed variations between two medical consultants. Inflammatory involvement of pleura was seen in 69.3% cases and 30.7% were due to oedema disorders. Concordance between observers was high for crepitations (95.5%) and pleural rub (93.8%) followed by vocal resonance (87.6%), dull percussion note (76.9%) and mediastinal shift (76.9%).

Methaemoglobinemia in nitrobenzene poisoning.

A young girl with nitrobenzene induced methaemoglobinaemia was saved by the timely use of mechanical ventilator, administration of oral methylene blue and parenteral ascorbic acid. Though parenteral methylene blue is the antidote of choice, due to its non-availability, the laboratory preparation of methylene blue have been utilized orally. The rare occurrence of such cases, and the efficacy of oral methylene blue and other supportive measures in evading death due to Nitrobenzene poisoning have been highlighted.

Methaemoglobinaemia in nitrobenzene poisoning--a case report.

A 24-year-old female of nitrobenzene poisoning presented with features of methaemoglobinaemia. She was treated with oral methylene blue and intravenous ascorbic acid and responded favourably from 3rd day onwards. The case is reported in details.