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October 28, 1992

The Rational Clinical Examination

Author Affiliations

Wexford, Pa

JAMA. 1992;268(16):2165. doi:10.1001/jama.1992.03490160034010

To the Editor.  —The article by Drs Williams and Simel1 is a laudable contribution to the study of bedside diagnosis to which JAMA has wisely made a commitment. I would like to add some additional comments concerning the diagnosis of ascites by physical examination.In my experience, the combination of abdominal distention, bulging flanks, and an everted umbilicus is almost always due to ascites. Rarely, false positives such as a large ovarian cyst will produce this sign. Unfortunately, the sign of the everted umbilicus has not been subjected to rigorous study. A valuable technique taught by Jack Myers, MD, (famed clinician and professor emeritus at the University of Pittsburgh [Pa]) consists of placing the examiner's hands, volar side up, under both bulging flanks of the supine patient, followed by flicking the flanks upward a few inches. If ascites is present, a fluid wave will be felt falling into the