Liver Disease Exam

Inspection

General:

  • Vitals – Tachycardia, Tachypnea, Fever
  • LOC or parietal signs (draw a pentagram or star)
  • Respiration (Cheyne Stokes in encephalopathy, Kussmaul in acidosis, etc)
  • Fetor hepaticus (volatile sulfur compounds – bacteria in blood and urine as a result of defective hepatic metabolism)
  • Cachexia
  • Twitchy
  • Pallor



 

HEENT

  • Alopecia
  • Scleral icterus (also sublingual)
  • Parotid enlargement or tenderness in EtOH
  • Nystagmus
  • Kayser Fleischer rings (Wilson’s)
  • Virchow’s node
  • Arcus senilis (cloudy opaque arc or circle around the edge of the eye)
  • Xanthelasmas
  • Decreased tongue size
  • Pallor
  • Temporal wasting
  • Lymphadenopathy
  • Increased JVP

Skin

  • Jaundice
  • Ecchymoses
  • Petechiae
  • Spider hemangiomas
  • Alopecia
  • Bronze Diabetes

Hands

  • Dupuytren’s contracture
  • Leukonychia
  • Clubbing
  • Palmar erythema
  • Asterixis (flapping tremor)
  • Hypothenar/thenar eminence wasting
  • Terry’s nails (nail plate turns white with the appearance of ground glass, and the lunula is obliterated)
  • Xanthoma

Chest

  • Spider nevi (blanch to pressure with rapid refill from the central arteriole when pressure is released)
  • Gynecomastia and axillary alopecia
  • Pleural effusion

Cardiovascular

  • Bounding pulse
  • Systolic ejection murmur

Abdomen

  • Ascites
    • Shifting dullness – Patient supine, percuss from tumpanic bowel down to line of dullness and mark, then patient turns to side, wait 1 minute, remark line of dullness (limitations: mesenteric fat, feces in bowel, obesity, requires at least 500cc)
    • Fluid wave – press pt’s ulnar hand vertically in midline of abdomen, examiner taps flanks with R hand and feels impulses with L on opposite flank
    • Puddle sign – Pt prone x 5 minutes, then rise onto elbows, apply stethoscope to most dependent abdomen and flick flank repeatedly as move stethoscope across abdomen away from examiner, loudness increase at farther edge of puddle, no change when pt sits (limitations: at least 120cc
  • Bulging flanks
  • Umbilical herniation
  • Hepatomegaly
  • Tender nodes
  • Caput Medusa (thoraco-epigastric or peri-umbilical vein distention)
  • Splenomegaly (due to portal HTN)

Legs

  • Edema
  • Proximal muscle weakness
  • Muscle wasting in extremities

Genitals

  • Alopecia
  • Testicular atrophy

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