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:
Overview
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
- 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)