Acute liver failure physical examination

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

Physical Examination

Appearance of the Patient

• Patient with acute liver failure may be appearing fatigue and lethargic.
• The patients with acute liver failure with mild mental status changes such as altered sleep pattern at initial stages may become confused or develop a comatose condition in the later stage.

Vital Signs

• Low-grade fever if the acute liver is due to viral infection.
• Hypothermia / hyperthermia may be present
• Tachycardia may be present in shock liver/
• Low blood pressure may be present in shock liver.

Skin

• Jaundice
• Vesicular skin lesions can be seen if the acute liver failure is due to herpes simplex infection.

HEENT

• Icteric sclera
• If the acute liver failure causes cerebral edema, the ophthalmoscopic exam may reveal papilloedema.
• Pupillary changes can also be seen with increased intracranial pressure. In grade I encephalopathy, the pupils may have a normal response. In grade II to III encephalopathy, the pupils can be hyperresponsive. In grade III to IV encephalopathy, the pupils begin to respond slowly.

Neck

Not significant

Lungs

• Asymmetric chest expansion / Decreased chest expansion
• 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
• PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
• Heave / thrill
• Friction rub
• S1
• S2
• S3
• S4
• 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 due to ascites
• Diffuse abdominal tenderness.
• Abdominal tenderness in the right upper abdominal quadrant.
• Hepatomegaly

Back

• Point tenderness over __ vertebrae (e.g. L3-L4)
• Sacral edema
• Costovertebral angle tenderness bilaterally/unilaterally (may also be referred to as Murphy's punch sign, which is different from Murphy's sign that suggests cholecystitis. To avoid confusion, write "costovertebral angle tenderness")
• Buffalo hump

Genitourinary

• A pelvic/adnexal mass may be palpated
• Inflamed mucosa
• Clear/(color), foul-smelling/odorless penile/vaginal discharge

^{Write additional pathognomonic findings, such as discharge that resembles cottage cheese for C. albicans vulvovaginitis / fish-odor for T. vaginalis ifnection}

Extremities

• Clubbing
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy
• Fasciculations in the upper/lower extremity

Neuromuscular

Hepatic encephalopathy is included in the diagnostic criteria of acute liver failure. The findings in hepatic encephalopathy varies from subtle mental status changes to coma.

The presence of hepatic encephalopathy is one of the defining characteristics of acute liver failure. Findings in patients with hepatic encephalopathy are variable, ranging from changes in behavior to coma. Hepatic encephalopathy is graded from I to IV

Grades of Hepatic Encephalopathy Based on their clinical manifestation, different grades of hepatic encephalopathy are defined as: Grade I Grade I encephalopathy manifests with changes in behavior and minimal changes in the level of consciousness. Grade II Grade II encephalopathy manifests with inappropriate behavior, gross disorientation, drowsiness, and possibly asterixis. Grade III Grade III encephalopathy manifests with marked confusion, incoherent speech, and mostly sleeping but arousable to vocal stimuli. Grade IV Grade III encephalopathy manifests with comatose, unresponsive to pain, and decorticate or decerebrate posturing.