Hepatic encephalopathy physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];{{AE}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 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.

Physical Examination

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.

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 movement of the limbs(asterixis), slurred speech, writing disturbances, voice monotonous and Impaired memory.
• The presence of asterixis on physical examination is highly suggestive of hepatic encephalopathy.

Appearance of the Patient

• Patients with hepatic encephalopathy usually appear confused, drowsy and sometimes irritable.

Vital Signs

In patients with hepatic encephalopathy vital signs include:

• Blood pressure may be normal or 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:

• Yellow skin
• Protracted and disabling pruritus
• Spider angiomas
• Palmar erythema
• Description (Adapted from Dermatology Atlas)

  Description (Adapted from Dermatology Atlas)

• 

  Description (Adapted from Dermatology Atlas)

HEENT

• Icteric sclera
• Dilated pupils, sluggishly responsive to light
• Ophthalmoscopic exam may be abnormal with findings of papilledema

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)
• abdominal tenderness

• A palpable liver in the epigastrium
• Guarding may be present
• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test

Back

Physical examination of back is usually normal.

Genitourinary

Physical examination of genitourinary system is usually normal.

Neuromuscular

• Patient is usually oriented to persons, place, and time
• Altered mental status
• Glasgow coma scale is ___ / 15
• Clonus may be present
• Hyperreflexia / hyporeflexia / areflexia
• Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
• Muscle rigidity
• Proximal/distal muscle weakness unilaterally/bilaterally
• ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
• Unilateral/bilateral upper/lower extremity weakness
• 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
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy
• Fasciculations in the upper/lower extremity