Extrahepatic Manifestations of Liver Disease (OSCE)

NEUROLOGICAL

 * LOC, delirium, coma
 * asterixis (arms out, dorsiflexed hands, eyes closed → hepatic encephalopathy)

BREATHING

 * Cheyne-Stokes (encephalopathy)
 * Kussmaul (metabolic acidosis)
 * fetor hepaticus (musty liver breath)

EYES

 * scleral icterus

MOUTH

 * sublingual jaundice
 * parotid gland enlargement, tenderness

NECK

 * spider angiomata
 * blanching, necklace distribution, can be in the back
 * up to 2 in men and 5 in women is normal

HANDS

 * nails (clubbing, leukonychia, Lindsay’s, Terry’s nails)
 * palmar erythema (ulnar)
 * Dupuytren’s contracture
 * thenar muscle wasting

TRUNK

 * jaundice
 * clotting
 * ecchymosis (prothrombin deficiency)
 * purpura/petechiae (platelet deficiency)
 * ↑ estrogen (gynecomastia, testicular atrophy, loss of axillary and pubic hair)

ABDOMEN

 * caput medusa
 * ascites
 * bulging flanks
 * shifting dullness
 * fluid wave
 * hepatomegaly (initially large and firm, liver later shrinks)
 * splenomegaly

LOWER LEGS

 * lower extremity edema
 * be reluctant to diagnose ascites without seeing swollen legs