Exam of patient with Liver Disease

Question 1

Jaundice

Definition:

Answer 1

An abnormal yellowish discoloration of the skin & mucous membranes caused by accumulation of bile pigment.

Question 2

hemolytic jaundice due to?

Answer 2

due to increased bilirubin production from excessive breakdown of red cells

Question 3

hepatocellular jaundice due to?

Answer 3

due to disease of the liver parenchyma, e.g., alcoholic liver disease, drug-induced liver disease, viral hepatitis, or metastatic carcinoma

Question 4

obstructive jaundice due to?

Answer 4

due to mechanical obstruction of the biliary ducts outside the liver, e.g., choledocholithiasis or pancreatic carcinoma

Question 5

Hepatocellular Jaundice Characteristic findings are?

Answer 5

spider telangiectasias, palmar erythema, gynecomastia, dilated abdominal wall veins, splenomegaly, asterixis, & fetor hepaticus.

Question 6

Spider telangiectasias are?

Answer 6

dilated cutaneous blood vessels with three components: (1) a central arteriole (2) multiple radiating “legs”; and (3) surrounding erythema

Question 7

Palmar erythema is?

Answer 7

a symmetrical reddening of the surfaces of the palms, most pronounced over the hypothenar and thenar eminences.

Question 8

Asterixis

Answer 8

asterixis is one of the earliest findings of hepatic encephalopathy & is thus a finding typical of hepatocellular jaundice. To elicit the sign, the patient holds both arms outstretched with fingers spread apart. After a short latent period, both fingers & hands commence to “flap,” with abrupt movements occurring at irregular intervals of a fraction of a second to seconds (thus earning the name liver flap).

Question 9

Fetor hepaticus is?

Answer 9

the characteristic breath of patients with severe parenchymal disease, which has been likened to a mixture of rotten eggs & garlic.

Question 10

(Courvoisier Sign)

Answer 10

Obstructive Jaundice: Palpable Gallbladder: The presence of a smooth, nontender, distended gallbladder in a patient with jaundice is a traditional sign of obstructive jaundice.

Question 11

Detection of Jaundice

Answer 11

sensitivity serum bilirubin exceeds
2.5 to 3 mg/dL 70% to 80%
10 mg/dL 83%
15 mg/dL 96%

Question 12

increase the probability of hepatocellular jaundice

Answer 12

patients presenting with jaundice, the physical signs of portal hypertension (dilated abdominal veins, LR = 17.5; ascites, LR = 4.4; and palpable spleen, LR = 2.9), palmar erythema (LR = 9.8), & spider angiomas (LR = 4.7)

Question 13

the finding of a palpable gallbladder argues for?

Answer 13

obstructed bile ducts with an LR of 26

Question 14

the findings increasing the probability of cirrhosis the most are?

Answer 14

dilated abdominal wall veins (LR = 9.5), encephalopathy (irrational behavior, disordered consciousness, and asterixis; LR = 8.8), reduced body or pubic hair (LR = 8.8), gynecomastia (LR = 7), ascites (LR = 6.6), spider angiomas (LR = 4.5), palmar erythema (LR = 4.3), jaundice (LR = 3.8), & peripheral edema (LR = 3).

Question 15

Detecting Large Gastroesophageal Varices in Patients with Cirrhosis

Answer 15

no physical finding reliably predicts which patients have significant gastroesophageal varices (as detected by endoscopy).

Question 16

Detecting Hepatopulmonary Syndrome

Answer 16

Hepatopulmonary syndrome is a serious complication of cirrhosis causing intrapulmonary vascular shunting and significant hypoxemia.

Question 17

increased the probability of hepatopulmonary syndrome?

Answer 17

the findings of finger clubbing (LR = 4.6) & cyanosis (LR = 4.3)

Question 18

Palpation of the abdomen may reveal?

Answer 18

abnormal tenderness, tumors, hernias, aneurysms, or organomegaly (i.e., of the liver, spleen, or gallbladder).

Question 19

The liver span is?

Answer 19

the distance in centimeters between the upper border of the liver in the right midclavicular line (as determined by percussion, i.e., where lung resonance changes to liver dullness) & the lower border (as determined by either percussion or palpation).

Question 20

The clinician’s assessment of liver span?

Answer 20

almost always underestimates the actual value.

Question 21

The liver span is the same whether the patient is?

Answer 21

percussed during quiet respirations or full held expiration.

Question 22

Scintigraphy is a form of diagnostic test?

Answer 22

used in nuclear medicine, wherein radioisotopes are taken internally, & the emitted radiation is captured by external detectors (gamma cameras) to form two-dimensional images.

Question 23

Anatomically, the normal liver extends on average?

Answer 23

5 cm below the right costal margin at the midclavicular line

Question 24

The consistency of the liver parenchyma probably determines in part whether a liver is palpable, because?

Answer 24

in patients with cirrhosis, whose livers are smaller but firmer than normal, the liver’s edge is palpable 95% of the time.

Question 25

a few findings modestly increase the probability of cirrhosis:

Answer 25

an enlarged palpable liver edge (LR = 2.3), a palpable liver in the epigastrium (LR = 2.7), & a liver edge that is unusually firm (LR = 2.7).

Question 26

In patients with jaundice, the findings of a palpable liver & liver tenderness are?

Answer 26

unhelpful, both appearing equally as often in patients with hepatocellular disease (nonobstructive jaundice) as in those with obstructive jaundice.

Question 27

Auscultatory Percussion: Scratch Test

Answer 27

Auscultatory percussion is frequently used to locate the lower border of the liver. The moment the clinician’s percussing digit crosses the border of the liver & begins to strike the abdominal wall over the liver, the sound heard through the stethoscope becomes louder.

Question 28

Pulsatile Liver:

The finding of a pulsatile liver has been described in?

Answer 28

tricuspid regurgitation with high pulmonary pressures & constrictive pericarditis.

Question 29

Detection of Splenomegaly indicates that the finding of a palpable spleen?

Answer 29

increases greatly the probability of splenomegaly (LR = 8.5).

Question 30

The common causes of splenomegaly are?

Answer 30

hepatic disease (portal hypertension), hematologic disorders (leukemias, lymphomas, myelofibrosis), infectious disease (HIV infection), & primary splenic disorders (splenic infarction or hematoma).

Question 31

Splenomegaly Associated with lymphadenopathy

Answer 31

practically excludes hepatic disease and points to one of the other disorders (LR = 0.04).

Question 32

The finding of a palpable liver with splenomegaly

Answer 32

increases the probability of an underlying hepatic cause of splenomegaly (LR = 2.7)

Question 33

the finding of massive splenomegaly (the spleen extends to the level of the umbilicus) increases the probability of an underlying?

Answer 33

hematologic disease (LR = 2.1).

Question 34

In returning travelers from tropical countries who are febrile, the finding of a palpable spleen significantly increases the probability of?

Answer 34

malaria (LR = 6.5).

Question 35

Spleen Percussion Sign

Answer 35

useful way to measure splenic size in patients with infectious mononucleosis. The clinician percusses the lowest left intercostal space in the anterior axillary line (usually, the eighth or ninth); if the percussion note in this location, usually resonant, becomes dull with a full inspiration, the test is positive.

Question 36

Nixon Method

Answer 36

The patient is positioned in the right lateral decubitus position, & the clinician percusses from the lower level of pulmonary resonance in the posterior axillary line downward obliquely to the lower midanterior costal margin. The test is positive if the border of dullness on this line lies more than 8 cm from the costal margin.

Question 37

Traube Space Dullness

Answer 37

Traube space is the triangular space, normally tympanic, that is over the left lower anterior part of the chest. Its upper border is marked by the limits of cardiac dullness (usually, the sixth rib), its lower border is the costal margin, and its lateral border is the anterior axillary line. could be a sign of splenic enlargement.

Question 38

The Courvoisier sign is?

Answer 38

a palpable nontender gallbladder in a patient with jaundice, a finding that has been traditionally associated with malignant obstruction of the biliary system.

Question 39

Restricting Courvoisier sign positive sign as a palpable gallbladder in a jaundice patient, indicates that the?

Answer 39

Courvoisier sign is pathognomonic for extrahepatic obstruction of the biliary system (stones or malignant disease, LR = 26; not hepatocellular jaundice).

Question 40

Consequently, if there is a “law” to the Courvoisier sign, it is that the palpable gallbladder in a jaundiced patient indicates?

Answer 40

extrahepatic obstruction, not that the obstruction is caused by malignant disease.

Question 41

In supine patients with ascites?

Answer 41

peritoneal fluid gravitates to the flanks, & the air-filled intestines float to occupy the periumbilical space.

Question 42

Distribution of fluid & air causes four characteristic signs of ascites:

Answer 42

1. Bulging flanks
2. Flank dullness:
3. Shifting dullness:
4. Fluid wave:

Question 43

Ascites: Flank dullness is positive?

Answer 43

if there is a horizontal border between dullness in the flank area and resonance (or tympany) in the periumbilical area.

Question 44

Ascites: Shifting dullness describes flank dullness whose?

Answer 44

position shifts as the patient changes position, usually by rolling on to one side. In a patient with a positive response, the border between resonance and dullness shifts away from the side that is most dependent.

Question 45

Ascites: Fluid wave:

Answer 45

To elicit the fluid wave, the clinician places one hand against the lateral wall of the abdomen & uses the other hand to tap firmly on the opposite lateral wall. In the positive response, the tap generates a wave that is transmitted through the abdomen & felt as a sudden shock by the other hand.

Question 46

A significant cause of false-positive flank dullness or shifting dullness is accumulation of?

Answer 46

fluid within loops of the colon. This condition, called pseudoascites