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How to elicit puddle sign?

Puddle's sign
  • This sign is elicited to detect the presence of minimal fluid when flanks are resonant.
  • The term Puddle sign literally means a small pool of muddy water.
  • It can be elicited either by percussion or by auscultopercussion
  • Generally  300-400 ml of fluid may be clinically elicited by puddle sign and even as little as 120 ml of fluid can be detected by this method.
How to elicit puddle sign?
  • First percuss the abdomen in supine position where you get a tympanitic note in the midline.
  • Now place the patient on the hands and knees (knee-elbow position) for 5 minutes and percuss with difficulty over the dependent part of abdomen (near umbilicus) which now reveals a dull note due to shifting of fluid
  • Previously resonant umbilical region becomes dull if minimal fluid is present.
  • Place a stethoscope over umbilical region and scratch the abdominal wall from periphery towards umbilicus
  • A change in the quality of sound is perceived while crossing the fluid column. This sign is false positive in massive splenomegaly and distended bladder.