Hepatic encephalopathy physical examination: Difference between revisions

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Latest revision as of 15:48, 26 January 2018

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of asterixis. This is detected by having the patient hold out his outstretched arms and cocking his wrists back. In the presence of asterixis, there is a non-synchronized, intermittent flapping motion at the wrists. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as renal failure and carbon dioxide retention.

Physical Examination

Physical examination of patients with hepatic encephalopathy is usually remarkable for signs of personality changes, signs of altered level of consciousness, jerking movement of the limbs (asterixis), slurred speech, writing disturbances, monotonous voice and impaired memory^[1]^[2]^[3]

Appearance of the patient

Patients with hepatic encephalopathy usually appear confused, drowsy and sometimes irritable^[4]^[5]

Vital signs

In patients with hepatic encephalopathy vital signs include:^[6]

Blood pressure may be normal, low or high.
Hypothermia or hyperthermia may be present
Tachycardia with regular pulse may be present

Skin

Signs of liver disease may be seen, such as:^[7]

HEENT

Icteric sclera^[7]
Dilated pupils, sluggishly responsive to light^[8]
Ophthalmoscopic exam may be abnormal with findings of papilledema^[9]

Neck

Physical examination of neck is usually normal.

Lungs

Physical examination of lungs is usually normal

Heart

Physical examination of heart is usually normal

Abdomen

Signs of liver disease may be seen such as:

Fluid collection in the abdomen (ascites)^[10]
Abdominal tenderness^[11]
A palpable liver in the epigastrium (hepatomegaly- feel with inspiration, relocate during expiration)^[12]

Back

Physical examination of back is usually normal

Genitourinary

Physical examination of genitourinary system is usually normal

Neuromuscular

Jerking movement of the limbs (asterixis) is highly suggestive of hepatic encephalopathy^[3]
Attention deficit and slow information processing^[13]
Abnormal paper and pencil tests^[13]
Altered mental status may be seen^[14]
Scoring on Glasgow coma scale may be low
Clonus may be present^[8]
Hyporeflexia^[15]
Positive (abnormal) Babinski reflex^[16]
Bilaterally muscle weakness may be seen^[4]
Examination cranial nerves is usually normal

Extremities

Athetosis (writhing, sinuous movements of the digits and extremities) may be present

References

↑ Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.
↑ al-Arif A, Sporn MB (1972). "2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei". Proc Natl Acad Sci U S A. 69 (7): 1716–9. PMC 426785. PMID 4340155.
↑ ^3.0 ^3.1 Agarwal R, Baid R (2016). "Asterixis". J Postgrad Med. 62 (2): 115–7. doi:10.4103/0022-3859.180572. PMC 4944342. PMID 27089111.
↑ ^4.0 ^4.1 Bleibel W, Al-Osaimi AM (2012). "Hepatic encephalopathy". Saudi J Gastroenterol. 18 (5): 301–9. doi:10.4103/1319-3767.101123. PMC 3500018. PMID 23006457.
↑ Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ; et al. (2012). "Modified-orientation log to assess hepatic encephalopathy". Aliment Pharmacol Ther. 35 (8): 913–20. doi:10.1111/j.1365-2036.2012.05038.x. PMC 3616137. PMID 22348593.
↑ Wannhoff A, Nusshag C, Stremmel W, Merle U (2017). "Slow ventricular tachycardia presenting with acute liver failure". SAGE Open Med Case Rep. 5: 2050313X17718100. doi:10.1177/2050313X17718100. PMC 5528920. PMID 28835821.
↑ ^7.0 ^7.1 Dogra S, Jindal R (2011). "Cutaneous manifestations of common liver diseases". J Clin Exp Hepatol. 1 (3): 177–84. doi:10.1016/S0973-6883(11)60235-1. PMC 3940632. PMID 25755383.
↑ ^8.0 ^8.1 Shawcross DL, Wendon JA (2012). "The neurological manifestations of acute liver failure". Neurochem Int. 60 (7): 662–71. doi:10.1016/j.neuint.2011.10.006. PMID 22067133.
↑ Crippin JS, Gross JB, Lindor KD (1992). "Increased intracranial pressure and hepatic encephalopathy in chronic liver disease". Am J Gastroenterol. 87 (7): 879–82. PMID 1615943.
↑ Losowsky MS, Scott BB (1973). "Ascites and oedema in liver disease". Br Med J. 3 (5875): 336–8. PMC 1586440. PMID 4579401.
↑ Riley TR, Koch K (2003). "Characteristics of upper abdominal pain in those with chronic liver disease". Dig Dis Sci. 48 (10): 1914–8. PMID 14627332.
↑ McCormick PA, Nolan N (2004). "Palpable epigastric liver as a physical sign of cirrhosis: a prospective study". Eur J Gastroenterol Hepatol. 16 (12): 1331–4. PMID 15618841.
↑ ^13.0 ^13.1 Nabi E, Bajaj JS (2014). "Useful tests for hepatic encephalopathy in clinical practice". Curr Gastroenterol Rep. 16 (1): 362. doi:10.1007/s11894-013-0362-0. PMC 3918211. PMID 24357348.
↑ Rahimi RS, Elliott AC, Rockey DC (2013). "Altered mental status in cirrhosis: etiologies and outcomes". J Investig Med. 61 (4): 695–700. doi:10.2310/JIM.0b013e318289e254. PMID 23474970.
↑ ADAMS RD, FOLEY JM (1953). "The neurological disorder associated with liver disease". Res Publ Assoc Res Nerv Ment Dis. 32: 198–237. PMID 13134644.
↑ Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.

Template:WH Template:WS

[pmid28533911-1] Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.

[pmid4340155-2] -Arif A, Sporn MB (1972). "2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei". Proc Natl Acad Sci U S A. 69 (7): 1716–9. PMC 426785. PMID 4340155.

[pmid27089111-3] 3.0 ^3.1 Agarwal R, Baid R (2016). "Asterixis". J Postgrad Med. 62 (2): 115–7. doi:10.4103/0022-3859.180572. PMC 4944342. PMID 27089111.

[pmid23006457-4] 4.0 ^4.1 Bleibel W, Al-Osaimi AM (2012). "Hepatic encephalopathy". Saudi J Gastroenterol. 18 (5): 301–9. doi:10.4103/1319-3767.101123. PMC 3500018. PMID 23006457.

[pmid22348593-5] Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ; et al. (2012). "Modified-orientation log to assess hepatic encephalopathy". Aliment Pharmacol Ther. 35 (8): 913–20. doi:10.1111/j.1365-2036.2012.05038.x. PMC 3616137. PMID 22348593.

[pmid28835821-6] Wannhoff A, Nusshag C, Stremmel W, Merle U (2017). "Slow ventricular tachycardia presenting with acute liver failure". SAGE Open Med Case Rep. 5: 2050313X17718100. doi:10.1177/2050313X17718100. PMC 5528920. PMID 28835821.

[pmid25755383-7] 7.0 ^7.1 Dogra S, Jindal R (2011). "Cutaneous manifestations of common liver diseases". J Clin Exp Hepatol. 1 (3): 177–84. doi:10.1016/S0973-6883(11)60235-1. PMC 3940632. PMID 25755383.

[pmid22067133-8] 8.0 ^8.1 Shawcross DL, Wendon JA (2012). "The neurological manifestations of acute liver failure". Neurochem Int. 60 (7): 662–71. doi:10.1016/j.neuint.2011.10.006. PMID 22067133.

[pmid1615943-9] Crippin JS, Gross JB, Lindor KD (1992). "Increased intracranial pressure and hepatic encephalopathy in chronic liver disease". Am J Gastroenterol. 87 (7): 879–82. PMID 1615943.

[pmid4579401-10] Losowsky MS, Scott BB (1973). "Ascites and oedema in liver disease". Br Med J. 3 (5875): 336–8. PMC 1586440. PMID 4579401.

[pmid14627332-11] Riley TR, Koch K (2003). "Characteristics of upper abdominal pain in those with chronic liver disease". Dig Dis Sci. 48 (10): 1914–8. PMID 14627332.

[pmid15618841-12] McCormick PA, Nolan N (2004). "Palpable epigastric liver as a physical sign of cirrhosis: a prospective study". Eur J Gastroenterol Hepatol. 16 (12): 1331–4. PMID 15618841.

[pmid24357348-13] 13.0 ^13.1 Nabi E, Bajaj JS (2014). "Useful tests for hepatic encephalopathy in clinical practice". Curr Gastroenterol Rep. 16 (1): 362. doi:10.1007/s11894-013-0362-0. PMC 3918211. PMID 24357348.

[pmid23474970-14] Rahimi RS, Elliott AC, Rockey DC (2013). "Altered mental status in cirrhosis: etiologies and outcomes". J Investig Med. 61 (4): 695–700. doi:10.2310/JIM.0b013e318289e254. PMID 23474970.

[pmid13134644-15] ADAMS RD, FOLEY JM (1953). "The neurological disorder associated with liver disease". Res Publ Assoc Res Nerv Ment Dis. 32: 198–237. PMID 13134644.

[pmid28680841-16] Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Hepatic encephalopathy}}
-{{CMG}};{{AE}{{MMJ}}
+{{CMG}};{{AE}}{{MMJ}}
 ==Overview==
-In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of [[asterixis]]. This is detected by having the patient hold out his outstretched arms and hands and cock his wrists back. In the presence of asterixis, there is a non-synchronized, intermittent flapping motion at the wrists. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as [[renal failure]] and [[carbon dioxide]] retention.
+In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of [[asterixis]]. This is detected by having the patient hold out his outstretched arms and cocking his [[Wrist|wrists]] back. In the presence of [[asterixis]], there is a non-synchronized, intermittent flapping motion at the [[Wrist|wrists]]. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as [[renal failure]] and [[carbon dioxide]] retention.
-==Physical Examination==
-===Skin===
-Signs of [[Liver diseases|liver disease]], may be seen such as:<ref name="pmid25755383">{{cite journal| author=Dogra S, Jindal R| title=Cutaneous manifestations of common liver diseases. | journal=J Clin Exp Hepatol | year= 2011 | volume= 1 | issue= 3 | pages= 177-84 | pmid=25755383 | doi=10.1016/S0973-6883(11)60235-1 | pmc=3940632 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25755383  }} </ref>
-*[[Yellow skin]] and eyes
-*Protracted and disabling [[pruritus]]
-*[[Spider angioma|Spider angiomas]]
-*[[Palmar erythema]]
-===Nose===
-*Signs of liver disease, such as musty odor to the breath.
-===Abdomen===
-*Signs of liver disease, such fluid collection in the abdomen ([[ascites]]), and occasionally a musty odor urine.
-===Neurologic===
-Nervous system signs may change. Signs include:
-*Coarse, "flapping" shaking of the hands when attempting to hold the arms out in front of the body and lift the hands.
-*Abnormal mental status, particularly cognitive (thinking) tasks such as connecting numbers with lines.
-==References==
-{{Reflist|2}}
-[[Category:Disease]]
-[[Category:Gastroenterology]]
-[[Category:Hepatology]]
-[[Category:Neurology]]
-[[Category:Emergency medicine]]
-{{WH}}
-{{WS}}
-==Overview==
-Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
-OR
-Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
-OR
-The presence of [finding(s)] on physical examination is diagnostic of [disease name].
-OR
-The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
 ==Physical Examination==
-*Physical examination of patients with hepatic encephalopathy is usually remarkable for: signs of [[personality changes]], signs of altered level of [[consciousness]], observing [[Jerking|jerking movement]] of the limbs([[asterixis]]), [[slurred speech]], writing disturbances, voice monotonous and [[Impaired memory]].<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref><ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
+*[[Physical examination]] of patients with hepatic encephalopathy is usually remarkable for signs of [[personality changes]], signs of altered level of [[consciousness]], [[Jerking|jerking movement]] of the [[limbs]] ([[asterixis]]), [[slurred speech]], writing disturbances,  monotonous voice and [[impaired memory]]<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref><ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
-*The presence of [[asterixis]] on physical examination is highly suggestive of hepatic encephalopathy.<ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
+===Appearance of the patient===
-===Appearance of the Patient===
+*Patients with hepatic encephalopathy usually appear [[Confusion|confused]], [[Drowsiness|drowsy]] and sometimes [[irritable]]<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref><ref name="pmid22348593">{{cite journal| author=Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ et al.| title=Modified-orientation log to assess hepatic encephalopathy. | journal=Aliment Pharmacol Ther | year= 2012 | volume= 35 | issue= 8 | pages= 913-20 | pmid=22348593 | doi=10.1111/j.1365-2036.2012.05038.x | pmc=3616137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22348593  }} </ref>
-*Patients with hepatic encephalopathy usually appear confused, drowsy and sometimes [[irritable]].<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref>
-===Vital Signs===
+===Vital signs===
 In patients with hepatic encephalopathy [[vital signs]] include:<ref name="pmid28835821">{{cite journal| author=Wannhoff A, Nusshag C, Stremmel W, Merle U| title=Slow ventricular tachycardia presenting with acute liver failure. | journal=SAGE Open Med Case Rep | year= 2017 | volume= 5 | issue=  | pages= 2050313X17718100 | pmid=28835821 | doi=10.1177/2050313X17718100 | pmc=5528920 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28835821  }} </ref>
-*[[Blood pressure]] may be normal or low or high.
+*[[Blood pressure]] may be normal, low or high.
 *[[Hypothermia]] or [[hyperthermia]] may be present
-*[[Tachycardia]] with regular pulse may be present
+*[[Tachycardia]] with regular [[pulse]] may be present
 ===Skin===
-*[[Cyanosis]]
+Signs of [[Liver diseases|liver disease]] may be seen, such as:<ref name="pmid25755383">{{cite journal| author=Dogra S, Jindal R| title=Cutaneous manifestations of common liver diseases. | journal=J Clin Exp Hepatol | year= 2011 | volume= 1 | issue= 3 | pages= 177-84 | pmid=25755383 | doi=10.1016/S0973-6883(11)60235-1 | pmc=3940632 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25755383  }} </ref>
-*[[Jaundice]]
+*[[Yellow skin]]
-*[[Pallor]]
+*Protracted and disabling [[pruritus]]
-*Bruises<gallery widths="150px">
+*[[Spider angioma|Spider angiomas]]
+*[[Palmar erythema]]
+===HEENT===
+*[[Icterus (medicine)|Icteric]] [[sclera]]<ref name="pmid25755383" />
+*[[Mydriasis|Dilated pupils]], sluggishly responsive to light<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
+*[[Ophthalmoscopy|Ophthalmoscopic]] exam may be abnormal with findings of [[papilledema]]<ref name="pmid1615943">{{cite journal| author=Crippin JS, Gross JB, Lindor KD| title=Increased intracranial pressure and hepatic encephalopathy in chronic liver disease. | journal=Am J Gastroenterol | year= 1992 | volume= 87 | issue= 7 | pages= 879-82 | pmid=1615943 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1615943  }} </ref>
-UploadedImage-01.jpg | Description {{dermref}}
+===Neck===
-UploadedImage-02.jpg | Description {{dermref}}
+[[Physical examination]] of neck is usually normal.
-</gallery>
-===HEENT===
-*Abnormalities of the head/hair may include ___
-*Evidence of trauma
-*Icteric sclera
-*[[Nystagmus]]
-*Extra-ocular movements may be abnormal
-*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
-*Ophthalmoscopic exam may be abnormal with findings of ___
-*Hearing acuity may be reduced
-*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
-*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
-*[[Exudate]] from the ear canal
-*Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
-*Inflamed nares / congested nares
-*[[Purulent]] exudate from the nares
-*Facial tenderness
-*Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
-===Neck===
-*[[Jugular venous distension]]
-*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
-*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
-*[[Thyromegaly]] / thyroid nodules
-*[[Hepatojugular reflux]]
 ===Lungs===
-*Asymmetric chest expansion / Decreased chest expansion
+[[Physical examination]] of [[lungs]] is usually normal
-*Lungs are hypo/hyperresonant
-*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
-*Rhonchi
-*Vesicular breath sounds / Distant breath sounds
-*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
-*[[Wheezing]] may be present
-*[[Egophony]] present/absent
-*[[Bronchophony]] present/absent
-*Normal/reduced [[tactile fremitus]]
 ===Heart===
-*Chest tenderness upon palpation
+[[Physical examination]] of [[heart]] is usually normal
-*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
-*[[Heave]] / [[thrill]]
-*[[Friction rub]]
-*[[Heart sounds#First heart tone S1.2C the .22lub.22.28components M1 and T1.29|S1]]
-*[[Heart sounds#Second heart tone S2 the .22dub.22.28components A2 and P2.29|S2]]
-*[[Heart sounds#Third heart sound S3|S3]]
-*[[Heart sounds#Fourth heart sound S4|S4]]
-*[[Heart sounds#Summation Gallop|Gallops]]
-*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
 ===Abdomen===
-*[[Abdominal distention]]
+Signs of liver disease may be seen such as:
-*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
+* Fluid collection in the [[abdomen]] ([[ascites]])<ref name="pmid4579401">{{cite journal| author=Losowsky MS, Scott BB| title=Ascites and oedema in liver disease. | journal=Br Med J | year= 1973 | volume= 3 | issue= 5875 | pages= 336-8 | pmid=4579401 | doi= | pmc=1586440 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4579401  }} </ref>
-*[[Rebound tenderness]] (positive Blumberg sign)
+* [[Abdominal tenderness]]<ref name="pmid14627332">{{cite journal| author=Riley TR, Koch K| title=Characteristics of upper abdominal pain in those with chronic liver disease. | journal=Dig Dis Sci | year= 2003 | volume= 48 | issue= 10 | pages= 1914-8 | pmid=14627332 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14627332  }} </ref>
-*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
+*A palpable [[liver]] in the [[epigastrium]] ([[hepatomegaly]]- feel with [[inspiration]], relocate during [[expiration]])<ref name="pmid15618841">{{cite journal| author=McCormick PA, Nolan N| title=Palpable epigastric liver as a physical sign of cirrhosis: a prospective study. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 12 | pages= 1331-4 | pmid=15618841 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15618841  }} </ref>
-*Guarding may be present
-*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
-*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 ===Back===
-*Point tenderness over __ vertebrae (e.g. L3-L4)
+[[Physical examination]] of back is usually normal
-*Sacral edema
-*Costovertebral angle tenderness bilaterally/unilaterally
-*Buffalo hump
 ===Genitourinary===
-*A pelvic/adnexal mass may be palpated
+[[Physical examination]] of [[genitourinary system]] is usually normal
-*Inflamed mucosa
-*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 ===Neuromuscular===
-*Patient is usually oriented to persons, place, and time
+*J[[Jerking|erking movement]] of the [[limbs]] ([[asterixis]]) is highly suggestive of hepatic encephalopathy<ref name="pmid27089111" />
-*Altered mental status
+*[[Attention deficit]] and slow information processing<ref name="pmid24357348">{{cite journal| author=Nabi E, Bajaj JS| title=Useful tests for hepatic encephalopathy in clinical practice. | journal=Curr Gastroenterol Rep | year= 2014 | volume= 16 | issue= 1 | pages= 362 | pmid=24357348 | doi=10.1007/s11894-013-0362-0 | pmc=3918211 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24357348  }} </ref>
-*Glasgow coma scale is ___ / 15
+*Abnormal paper and pencil tests<ref name="pmid24357348">{{cite journal| author=Nabi E, Bajaj JS| title=Useful tests for hepatic encephalopathy in clinical practice. | journal=Curr Gastroenterol Rep | year= 2014 | volume= 16 | issue= 1 | pages= 362 | pmid=24357348 | doi=10.1007/s11894-013-0362-0 | pmc=3918211 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24357348  }} </ref>
-*Clonus may be present
+*[[Altered mental status]] may be seen<ref name="pmid23474970">{{cite journal| author=Rahimi RS, Elliott AC, Rockey DC| title=Altered mental status in cirrhosis: etiologies and outcomes. | journal=J Investig Med | year= 2013 | volume= 61 | issue= 4 | pages= 695-700 | pmid=23474970 | doi=10.2310/JIM.0b013e318289e254 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23474970  }} </ref>
-*Hyperreflexia / hyporeflexia / areflexia
+*Scoring on [[Glasgow coma scale]] may be low
-*Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
+*[[Clonus]] may be present<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
-*Muscle rigidity
+*[[Hyporeflexia]]<ref name="pmid13134644">{{cite journal| author=ADAMS RD, FOLEY JM| title=The neurological disorder associated with liver disease. | journal=Res Publ Assoc Res Nerv Ment Dis | year= 1953 | volume= 32 | issue=  | pages= 198-237 | pmid=13134644 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13134644  }} </ref>
-*Proximal/distal muscle weakness unilaterally/bilaterally
+*Positive (abnormal) [[Plantar reflex|Babinski reflex]]<ref name="pmid28680841">{{cite journal| author=Djiambou-Nganjeu H| title=Hepatic Encephalopathy in Liver Cirrhosis. | journal=J Transl Int Med | year= 2017 | volume= 5 | issue= 1 | pages= 64-67 | pmid=28680841 | doi=10.1515/jtim-2017-0013 | pmc=5490964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28680841  }} </ref>
-*____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
+*[[Bilateral|Bilaterally]] [[muscle weakness]] may be seen<ref name="pmid23006457">{{cite journal| author=Bleibel W, Al-Osaimi AM| title=Hepatic encephalopathy. | journal=Saudi J Gastroenterol | year= 2012 | volume= 18 | issue= 5 | pages= 301-9 | pmid=23006457 | doi=10.4103/1319-3767.101123 | pmc=3500018 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23006457  }} </ref>
-*Unilateral/bilateral upper/lower extremity weakness
+*Examination [[cranial nerves]] is usually normal
-*Unilateral/bilateral sensory loss in the upper/lower extremity
-*Positive straight leg raise test
-*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
-*Positive/negative Trendelenburg sign
-*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
-*Normal finger-to-nose test / Dysmetria
-*Absent/present dysdiadochokinesia (palm tapping test)
 ===Extremities===
-*[[Clubbing]]
+* [[Athetosis]] (writhing, sinuous movements of the digits and [[extremities]]) may be present
-*[[Cyanosis]]
-*Pitting/non-pitting [[edema]] of the upper/lower extremities
-*Muscle atrophy
-*Fasciculations in the upper/lower extremity
 ==References==
 {{Reflist|2}}{{WH}} {{WS}}