Jaundice physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Jaundice}} | {{Jaundice}} | ||
{{CMG}} | {{CMG}}; {{AE}}{{FKH}} | ||
==Overview== | ==Overview== | ||
==Physical Examination== | ==Physical Examination== | ||
* Jaundice is seen with a number of disorders. Physical examination of patients with jaundice is based on underlying [[disease]]. | * Jaundice is seen with a number of disorders. Physical examination of patients with jaundice is based on underlying [[disease]]. | ||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
* [[Cirrhosis]] : | * [[Cirrhosis]]: | ||
** [[Patient|Patients]] usually appear weak due to constitutional [[Symptom|symptoms]] such as [[weight loss]], [[anorexia]] and [[muscle atrophy]]. Yellowish discoloration of [[skin]] and [[abdominal distension]] may also be present due to [[ascites]].<ref name="pmid104230702">{{cite journal|year=1999|title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function|url=|journal=Scand. J. Gastroenterol.|volume=34|issue=5|pages=520–3|doi=|pmid=10423070|vauthors=Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH, Hou MC, Chu CJ, Chan CC, Luo JC, Lee SD}}</ref><ref name="pmid18328931" /> | |||
* [[Viral hepatitis]]: | * [[Viral hepatitis]]: | ||
* The appearance of the patient on presentation depends on his/her age. Younger patients tend to be [[asymptomatic]], while [[symptomatic]] patients tend to be older. [[Symptomatic]] patients may have a range of symptoms that can vary in severity from a mild [[flu]]-like illness to fulminant hepatitis. Patients with fulminant hepatitis are usually [[disoriented]] and very ill-looking. | ** The appearance of the patient on presentation depends on his/her age. Younger patients tend to be [[asymptomatic]], while [[symptomatic]] patients tend to be older. [[Symptomatic]] patients may have a range of symptoms that can vary in severity from a mild [[flu]]-like illness to fulminant hepatitis. Patients with fulminant hepatitis are usually [[disoriented]] and very ill-looking.<ref name="pmid19399815" /> | ||
* [[ | * [[Pancreatic cancer (patient information)|Pancreatic cancer]]: | ||
* Patients with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with signs of [[malnutrition]]. | ** Patients with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with signs of [[malnutrition]].<ref name="pmid15522652" /> | ||
===Vital Signs=== | ===Vital Signs=== | ||
* [[Fever]], [[tachycardia]], [[hypotension]], [[tachypnea]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | * [[Fever]], [[tachycardia]], [[hypotension]], [[tachypnea]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | ||
===Skin=== | ===Skin=== | ||
* Jaundice is visible in conjunctiva, skin and mucosa when the serum bilirubin level rises above 2 mg/dL. | * Jaundice is visible in conjunctiva, skin, and mucosa when the serum bilirubin level rises above 2 mg/dL. | ||
* Jaundice, [[palmar erythema]], [[Spider angioma|spider angiomata]], [[gynecomastia]] may be present in [[viral hepatitis]]. <ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | * Jaundice, [[palmar erythema]], [[Spider angioma|spider angiomata]], [[gynecomastia]] may be present in [[viral hepatitis]]. <ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | ||
* [[Pallor]], [[Bruise|bruises]], [[palmar erythema]] on the [[Thenar eminence|thenar]] and [[Hypothenar eminence|hypothenar eminences]], [[Spider angioma|spider angiomata]], [[Telangiectasia|telangiectasias]] may be present in [[cirrhosis]].<ref name="pmid10423070">{{cite journal |vauthors=Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH, Hou MC, Chu CJ, Chan CC, Luo JC, Lee SD |title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function |journal=Scand. J. Gastroenterol. |volume=34 |issue=5 |pages=520–3 |year=1999 |pmid=10423070 |doi= |url=}}</ref> | * [[Pallor]], [[Bruise|bruises]], [[palmar erythema]] on the [[Thenar eminence|thenar]] and [[Hypothenar eminence|hypothenar eminences]], [[Spider angioma|spider angiomata]], [[Telangiectasia|telangiectasias]] may be present in [[cirrhosis]].<ref name="pmid10423070">{{cite journal |vauthors=Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH, Hou MC, Chu CJ, Chan CC, Luo JC, Lee SD |title=Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function |journal=Scand. J. Gastroenterol. |volume=34 |issue=5 |pages=520–3 |year=1999 |pmid=10423070 |doi= |url=}}</ref> | ||
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===HEENT=== | ===HEENT=== | ||
* Thinning of hair on the scalp due to [[hyperestrogenism]], [[Parotid gland|parotid gland]] enlargement, [[fetor hepaticus]] may be present in [[Cirrhosis|cirrhosis.]] <ref name="pmid18328931">{{cite journal |vauthors=Schuppan D, Afdhal NH |title=Liver cirrhosis |journal=Lancet |volume=371 |issue=9615 |pages=838–51 |year=2008 |pmid=18328931 |pmc=2271178 |doi=10.1016/S0140-6736(08)60383-9 |url=}}</ref> | * Thinning of hair on the scalp due to [[hyperestrogenism]], [[Parotid gland|parotid gland]] enlargement, and [[fetor hepaticus]] may be present in [[Cirrhosis|cirrhosis.]] <ref name="pmid18328931">{{cite journal |vauthors=Schuppan D, Afdhal NH |title=Liver cirrhosis |journal=Lancet |volume=371 |issue=9615 |pages=838–51 |year=2008 |pmid=18328931 |pmc=2271178 |doi=10.1016/S0140-6736(08)60383-9 |url=}}</ref> | ||
===Neck=== | ===Neck=== | ||
* [[Cervical]] [[lymphadenopathy]] may be present in | * [[Cervical]] [[lymphadenopathy]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | ||
* Signs of [[Metastasis|metastatic disease]] include: | * Signs of [[Metastasis|metastatic disease]] include: | ||
** Left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]) | ** Left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]) | ||
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===Genitourinary=== | ===Genitourinary=== | ||
* [[Testicular atrophy]] | * [[Testicular atrophy]] may be present in [[cirrhosis]].[[Jaundice physical examination#cite note-pmid18328931-4|<sup>[4]</sup>]] | ||
* [[Metastasis|Metastatic]] palpable mass may be present in the [[rectal]] pouch (''Blumer's shelf'') in advanced stages of [[pancreatic cancer]].<ref name="pmid9490607">{{cite journal |vauthors=Galvañ VG |title=Sister Mary Joseph's nodule |journal=Ann. Intern. Med. |volume=128 |issue=5 |pages=410 |year=1998 |pmid=9490607 |doi= |url=}}</ref> | * [[Metastasis|Metastatic]] palpable mass may be present in the [[rectal]] pouch (''Blumer's shelf'') in advanced stages of [[pancreatic cancer]].<ref name="pmid9490607">{{cite journal |vauthors=Galvañ VG |title=Sister Mary Joseph's nodule |journal=Ann. Intern. Med. |volume=128 |issue=5 |pages=410 |year=1998 |pmid=9490607 |doi= |url=}}</ref> | ||
===Neurologic=== | ===Neurologic=== | ||
* [[Altered mental status]], [[encephalopathy]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | * [[Altered mental status]], [[encephalopathy]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | ||
* Alteration of [[Mental status examination|mental status ,]] confusion, coma, asterixis may be present in [[hepatic encephalopathy]].<ref name="pmid28533911">{{cite journal |vauthors=Ferenci P |title=Hepatic encephalopathy |journal=Gastroenterol Rep (Oxf) |volume=5 |issue=2 |pages=138–147 |year=2017 |pmid=28533911 |pmc=5421503 |doi=10.1093/gastro/gox013 |url=}}</ref> | * Alteration of [[Mental status examination|mental status,]] confusion, [[coma]], and asterixis may be present in [[hepatic encephalopathy]].<ref name="pmid28533911">{{cite journal |vauthors=Ferenci P |title=Hepatic encephalopathy |journal=Gastroenterol Rep (Oxf) |volume=5 |issue=2 |pages=138–147 |year=2017 |pmid=28533911 |pmc=5421503 |doi=10.1093/gastro/gox013 |url=}}</ref> | ||
===Extremities=== | ===Extremities=== | ||
* [[Peripheral edema]], [[dupuytren's contracture]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | * [[Peripheral edema]], [[dupuytren's contracture]] may be present in [[viral hepatitis]].<ref name="pmid19399815">{{cite journal |vauthors=Rotman Y, Brown TA, Hoofnagle JH |title=Evaluation of the patient with hepatitis B |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S22–7 |year=2009 |pmid=19399815 |pmc=2881483 |doi=10.1002/hep.22976 |url=}}</ref> | ||
* [[Edema]] of the lower extremities, [[muscle atrophy]], nail changes, [[clubbing]] may be present in [[cirrhosis]].[[Jaundice physical examination#cite note-pmid18328931-4|<sup>[4]</sup>]] <ref name="pmid133161432">{{cite journal |vauthors=MUEHRCKE RC |title=The finger-nails in chronic hypoalbuminaemia; a new physical sign |journal=Br Med J |volume=1 |issue=4979 |pages=1327–8 |year=1956 |pmid=13316143 |pmc=1980060 |doi= |url=}}</ref> | * [[Edema]] of the lower extremities, [[muscle atrophy]], nail changes, and [[clubbing]] may be present in [[cirrhosis]].[[Jaundice physical examination#cite note-pmid18328931-4|<sup>[4]</sup>]]<ref name="pmid133161432">{{cite journal |vauthors=MUEHRCKE RC |title=The finger-nails in chronic hypoalbuminaemia; a new physical sign |journal=Br Med J |volume=1 |issue=4979 |pages=1327–8 |year=1956 |pmid=13316143 |pmc=1980060 |doi= |url=}}</ref> | ||
==References== | ==References== | ||
Revision as of 16:25, 5 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farnaz Khalighinejad, MD [2]
Overview
Physical Examination
- Jaundice is seen with a number of disorders. Physical examination of patients with jaundice is based on underlying disease.
Appearance of the Patient
- Cirrhosis:
- Patients usually appear weak due to constitutional symptoms such as weight loss, anorexia and muscle atrophy. Yellowish discoloration of skin and abdominal distension may also be present due to ascites.[1][2]
- Viral hepatitis:
- The appearance of the patient on presentation depends on his/her age. Younger patients tend to be asymptomatic, while symptomatic patients tend to be older. Symptomatic patients may have a range of symptoms that can vary in severity from a mild flu-like illness to fulminant hepatitis. Patients with fulminant hepatitis are usually disoriented and very ill-looking.[3]
- Pancreatic cancer:
- Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition.[4]
Vital Signs
- Fever, tachycardia, hypotension, tachypnea may be present in viral hepatitis.[3]
Skin
- Jaundice is visible in conjunctiva, skin, and mucosa when the serum bilirubin level rises above 2 mg/dL.
- Jaundice, palmar erythema, spider angiomata, gynecomastia may be present in viral hepatitis. [3]
- Pallor, bruises, palmar erythema on the thenar and hypothenar eminences, spider angiomata, telangiectasias may be present in cirrhosis.[5]
- Bullous pemphigoid, cicatricial pemphigoid, migratory superficial thrombophlebitis (classic Trousseau's syndrome), pancreatic panniculitis may be present in pancreatic cancer.[4][6]
HEENT
- Thinning of hair on the scalp due to hyperestrogenism, parotid gland enlargement, and fetor hepaticus may be present in cirrhosis. [2]
Neck
- Cervical lymphadenopathy may be present in viral hepatitis.[3]
- Signs of metastatic disease include:
- Left supraclavicular lymphadenopathy (Virchow's node)
- Palpable periumbilical mass (Sister Mary Joseph's node)
- Metastatic palpable mass in the rectal pouch (Blumer's shelf)
- Involvement of other nodes in the cervical area
may be present in pancreatic cancer.
Lungs
- Pulmonary examination: Normal
Heart
- Cardiovascular examination: Normal
Abdomen
- Hepatomegaly with right upper quadrant tenderness, abdominal distention, abdominal tenderness, splenomegaly, ascites, caput medusae may be present in viral hepatitis. [3]
- Abdominal distension, caput medusa, hepatomegaly, splenomegaly, ascites may be present in cirrhosis. [2]
- Abdominal distention, abdominal tenderness, hepatosplenomegaly, fluid thrill and dullness to percussion may be present due to ascites in pancreatic cancer. [7][8]
Back
- Back examination: Normal
Genitourinary
- Testicular atrophy may be present in cirrhosis.[4]
- Metastatic palpable mass may be present in the rectal pouch (Blumer's shelf) in advanced stages of pancreatic cancer.[9]
Neurologic
- Altered mental status, encephalopathy may be present in viral hepatitis.[3]
- Alteration of mental status, confusion, coma, and asterixis may be present in hepatic encephalopathy.[10]
Extremities
- Peripheral edema, dupuytren's contracture may be present in viral hepatitis.[3]
- Edema of the lower extremities, muscle atrophy, nail changes, and clubbing may be present in cirrhosis.[4][11]
References
- ↑ Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH, Hou MC, Chu CJ, Chan CC, Luo JC, Lee SD (1999). "Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function". Scand. J. Gastroenterol. 34 (5): 520–3. PMID 10423070.
- ↑ 2.0 2.1 2.2 Schuppan D, Afdhal NH (2008). "Liver cirrhosis". Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMC 2271178. PMID 18328931.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Rotman Y, Brown TA, Hoofnagle JH (2009). "Evaluation of the patient with hepatitis B". Hepatology. 49 (5 Suppl): S22–7. doi:10.1002/hep.22976. PMC 2881483. PMID 19399815.
- ↑ 4.0 4.1 Khorana AA, Fine RL (2004). "Pancreatic cancer and thromboembolic disease". Lancet Oncol. 5 (11): 655–63. doi:10.1016/S1470-2045(04)01606-7. PMID 15522652.
- ↑ Li CP, Lee FY, Hwang SJ, Chang FY, Lin HC, Lu RH, Hou MC, Chu CJ, Chan CC, Luo JC, Lee SD (1999). "Spider angiomas in patients with liver cirrhosis: role of alcoholism and impaired liver function". Scand. J. Gastroenterol. 34 (5): 520–3. PMID 10423070.
- ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
- ↑ Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T (1988). "Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients". Cancer. 62 (1): 135–41. PMID 3164230.
- ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
- ↑ Galvañ VG (1998). "Sister Mary Joseph's nodule". Ann. Intern. Med. 128 (5): 410. PMID 9490607.
- ↑ Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.
- ↑ MUEHRCKE RC (1956). "The finger-nails in chronic hypoalbuminaemia; a new physical sign". Br Med J. 1 (4979): 1327–8. PMC 1980060. PMID 13316143.