Interpretation of Some Physical Findings
Finding | Possible Causes | Comments |
|---|---|---|
Hepatic abnormalities | ||
Hepatomegaly | Passive venous congestion Liver hemorrhage (into a cyst or the parenchyma) | — |
Palpable mass | Cancer | — |
Liver firmness, irregular shape, blunt edges, and few if any individual nodules | — | |
Tenderness | Passive congestion Liver hemorrhage | Because of patient anxiety, often overdiagnosed True liver tenderness (a deep-seated ache) best elicited by percussion or compression of the rib cage Occasionally, if severe, mimics peritonitis |
Friction rubs or bruits (rare) | Tumor Hereditary hemorrhagic telangiectasia (Osler Webber Rendu) | — |
Extrahepatic abnormalities | ||
Alcoholic hepatitis if chronic or severe Peritoneal carcinomatosis Generalized fluid retention (eg, heart failure, nephrotic syndrome, hypoalbuminemia) | Typically abdominal distention, shifting dullness, and fluid wave May not be detectable if volume is < 1500 mL | |
Visibly dilated abdominal veins (caput medusae) | Inferior vena cava obstruction | — |
Splenomegaly | Nonalcoholic cirrhosis | — |
Asterixis | Uremia Heart failure if severe | Bilateral, asynchronous flapping of dorsiflexed hands with the arms outstretched |
Fetor hepaticus | Sweet, pungent smell | |
Drowsiness and confusion | Drugs Brain or systemic disorders | Nonspecific |
Wasted extremities plus protuberant abdomen with ascites (cirrhotic habitus) | Cirrhosis if advanced Cancers with peritoneal metastases if advanced | — |
Drugs Pituitary, genetic, systemic, and endocrine disorders | Testicular atrophy, erectile dysfunction, infertility, and loss of libido | |
In men, gynecomastia, loss of axillary or chest hair, and female pattern of pubic hair | Alcohol use disorder if chronic Drugs Endocrine disorders | Gynecomastia differentiated from pseudogynecomastia (in overweight men) by examination |
Gynecomastia plus testicular atrophy | Alcohol use disorder if chronic Pituitary or other endocrine disorders | — |
Pregnancy Undernutrition if severe Alcohol use disorder if chronic (possibly) | After compression, blanching with peripherally directed blood flow (to the outside of the lesion) Possibly increased risk of severe cirrhosis and variceal hemorrhage as number of angiomas increases May occur as a normal variant (usually < 3) | |
Palmar erythema | Feminization (in men) Pregnancy Hematologic cancers Alcohol use disorder if chronic (possibly) | Often most obvious on thenar and hypothenar eminences |
In patients with cirrhosis, clubbing | Possibly advanced portosystemic shunting or biliary cirrhosis Lung disorders if chronic Cyanotic heart disease Infection (eg, infective endocarditis) if chronic | — |
Hyperbilirubinemia caused by conditions such as hepatic or biliary disorders, hemolysis, use of certain drugs, or inborn errors of metabolism | Visible when bilirubin level is > 2 to 2.5 mg/dL (> 34 to 43 micromol/L) Affects sclerae (unlike carotenemia) | |
Muddy skin pigmentation, excoriations caused by constant pruritus, and xanthelasmas or xanthomas (cutaneous lipid deposits) | Cholestasis (including primary biliary cholangitis) if chronic | — |
Parotid gland enlargement | Alcohol use if chronic (often present with alcohol-associated cirrhosis) | — |
Slate gray or bronze skin | Hemochromatosis with deposition of iron and melanin | — |
Alcohol use if chronic Cigarette use Complex regional pain syndrome Repetitive motion or vibration | — | |