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The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
==Physical Examination==
==Physical Examination==
*Physical examination of patients with hepatic encephalopathy is usually remarkable for: signs of [[personality changes]], signs of altered level of [[consciousness]], observing [[Jerking|jerking movement]] of the limbs([[asterixis]]), [[slurred speech]], writing disturbances, voice monotonous and [[Impaired memory]].<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref><ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
*Physical examination of patients with hepatic encephalopathy is usually remarkable for: signs of [[personality changes]], signs of altered level of [[consciousness]], observing [[Jerking|jerking movement]] of the [[limbs]]([[asterixis]]), [[slurred speech]], writing disturbances, voice monotonous and [[Impaired memory]].<ref name="pmid28533911">{{cite journal| author=Ferenci P| title=Hepatic encephalopathy. | journal=Gastroenterol Rep (Oxf) | year= 2017 | volume= 5 | issue= 2 | pages= 138-147 | pmid=28533911 | doi=10.1093/gastro/gox013 | pmc=5421503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533911  }} </ref><ref name="pmid4340155">{{cite journal| author=al-Arif A, Sporn MB| title=2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei. | journal=Proc Natl Acad Sci U S A | year= 1972 | volume= 69 | issue= 7 | pages= 1716-9 | pmid=4340155 | doi= | pmc=426785 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4340155  }} </ref><ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
*The presence of [[asterixis]] on physical examination is highly suggestive for hepatic encephalopathy.<ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
*The presence of [[asterixis]] on physical examination is highly suggestive for hepatic encephalopathy.<ref name="pmid27089111">{{cite journal| author=Agarwal R, Baid R| title=Asterixis. | journal=J Postgrad Med | year= 2016 | volume= 62 | issue= 2 | pages= 115-7 | pmid=27089111 | doi=10.4103/0022-3859.180572 | pmc=4944342 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27089111  }} </ref>
===Appearance of the Patient===
===Appearance of the Patient===
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*Protracted and disabling [[pruritus]]
*Protracted and disabling [[pruritus]]
*[[Spider angioma|Spider angiomas]]
*[[Spider angioma|Spider angiomas]]
*[[Palmar erythema]] <gallery widths="150px">
*[[Palmar erythema]]
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>
===HEENT===
===HEENT===
*Icteric [[sclera]]<ref name="pmid25755383" />
*Icteric [[sclera]]<ref name="pmid25755383" />
*[[Mydriasis|Dilated pupils]], sluggishly responsive to light<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
*[[Mydriasis|Dilated pupils]], sluggishly responsive to light<ref name="pmid22067133">{{cite journal| author=Shawcross DL, Wendon JA| title=The neurological manifestations of acute liver failure. | journal=Neurochem Int | year= 2012 | volume= 60 | issue= 7 | pages= 662-71 | pmid=22067133 | doi=10.1016/j.neuint.2011.10.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22067133  }} </ref>
*Ophthalmoscopic exam may be abnormal with findings of papilledema<ref name="pmid1615943">{{cite journal| author=Crippin JS, Gross JB, Lindor KD| title=Increased intracranial pressure and hepatic encephalopathy in chronic liver disease. | journal=Am J Gastroenterol | year= 1992 | volume= 87 | issue= 7 | pages= 879-82 | pmid=1615943 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1615943  }} </ref>
*Ophthalmoscopic exam may be abnormal with findings of [[papilledema]]<ref name="pmid1615943">{{cite journal| author=Crippin JS, Gross JB, Lindor KD| title=Increased intracranial pressure and hepatic encephalopathy in chronic liver disease. | journal=Am J Gastroenterol | year= 1992 | volume= 87 | issue= 7 | pages= 879-82 | pmid=1615943 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1615943  }} </ref>


===Neck===
===Neck===
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===Lungs===
===Lungs===
[[Physical examination]] of lungs is usually normal.
[[Physical examination]] of [[lungs]] is usually normal.


===Heart===
===Heart===
[[Physical examination]] of heart is usually normal.
[[Physical examination]] of [[heart]] is usually normal.


===Abdomen===
===Abdomen===
Signs of liver disease may be seen such as:
Signs of liver disease may be seen such as:
* Fluid collection in the abdomen ([[ascites]])<ref name="pmid4579401">{{cite journal| author=Losowsky MS, Scott BB| title=Ascites and oedema in liver disease. | journal=Br Med J | year= 1973 | volume= 3 | issue= 5875 | pages= 336-8 | pmid=4579401 | doi= | pmc=1586440 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4579401  }} </ref>
* Fluid collection in the [[abdomen]] ([[ascites]])<ref name="pmid4579401">{{cite journal| author=Losowsky MS, Scott BB| title=Ascites and oedema in liver disease. | journal=Br Med J | year= 1973 | volume= 3 | issue= 5875 | pages= 336-8 | pmid=4579401 | doi= | pmc=1586440 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4579401  }} </ref>
* [[abdominal tenderness]]<ref name="pmid14627332">{{cite journal| author=Riley TR, Koch K| title=Characteristics of upper abdominal pain in those with chronic liver disease. | journal=Dig Dis Sci | year= 2003 | volume= 48 | issue= 10 | pages= 1914-8 | pmid=14627332 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14627332  }} </ref>
* [[abdominal tenderness]]<ref name="pmid14627332">{{cite journal| author=Riley TR, Koch K| title=Characteristics of upper abdominal pain in those with chronic liver disease. | journal=Dig Dis Sci | year= 2003 | volume= 48 | issue= 10 | pages= 1914-8 | pmid=14627332 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14627332  }} </ref>
*A palpable liver in the [[epigastrium]]([[hepatomegaly]])<ref name="pmid15618841">{{cite journal| author=McCormick PA, Nolan N| title=Palpable epigastric liver as a physical sign of cirrhosis: a prospective study. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 12 | pages= 1331-4 | pmid=15618841 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15618841  }} </ref>
*A palpable liver in the [[epigastrium]]([[hepatomegaly]])<ref name="pmid15618841">{{cite journal| author=McCormick PA, Nolan N| title=Palpable epigastric liver as a physical sign of cirrhosis: a prospective study. | journal=Eur J Gastroenterol Hepatol | year= 2004 | volume= 16 | issue= 12 | pages= 1331-4 | pmid=15618841 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15618841  }} </ref>
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===Extremities===
===Extremities===
* [[Athetosis]](writhing, sinuous movements in the digits and extremities) may be presesnt
* [[Athetosis]](writhing, sinuous movements in the digits and [[extremities]]) may be presesnt


==References==
==References==
{{Reflist|2}}{{WH}} {{WS}}
{{Reflist|2}}{{WH}} {{WS}}

Revision as of 16:57, 19 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Overview

In addition to changed level of consciousness, the hallmark of hepatic encephalopathy on the physical examination is the presence of asterixis. This is detected by having the patient hold out his outstretched arms and hands and cock his wrists back. In the presence of asterixis, there is a non-synchronized, intermittent flapping motion at the wrists. Asterixis is not specific to hepatic encephalopathy. It may also be seen in states such as renal failure and carbon dioxide retention.

Overview

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Physical Examination

Appearance of the Patient

  • Patients with hepatic encephalopathy usually appear confused, drowsy and sometimes irritable.[4]

Vital Signs

In patients with hepatic encephalopathy vital signs include:[5]

Skin

Signs of liver disease, may be seen such as:[6]

HEENT

Neck

Physical examination of neck is usually normal.

Lungs

Physical examination of lungs is usually normal.

Heart

Physical examination of heart is usually normal.

Abdomen

Signs of liver disease may be seen such as:

Back

Physical examination of back is usually normal.

Genitourinary

Physical examination of genitourinary system is usually normal.

Neuromuscular

Extremities

References

  1. Ferenci P (2017). "Hepatic encephalopathy". Gastroenterol Rep (Oxf). 5 (2): 138–147. doi:10.1093/gastro/gox013. PMC 5421503. PMID 28533911.
  2. al-Arif A, Sporn MB (1972). "2'-O-methylation of adenosine, guanosine, uridine, and cytidine in RNA of isolated rat liver nuclei". Proc Natl Acad Sci U S A. 69 (7): 1716–9. PMC 426785. PMID 4340155.
  3. 3.0 3.1 3.2 Agarwal R, Baid R (2016). "Asterixis". J Postgrad Med. 62 (2): 115–7. doi:10.4103/0022-3859.180572. PMC 4944342. PMID 27089111.
  4. 4.0 4.1 Bleibel W, Al-Osaimi AM (2012). "Hepatic encephalopathy". Saudi J Gastroenterol. 18 (5): 301–9. doi:10.4103/1319-3767.101123. PMC 3500018. PMID 23006457.
  5. Wannhoff A, Nusshag C, Stremmel W, Merle U (2017). "Slow ventricular tachycardia presenting with acute liver failure". SAGE Open Med Case Rep. 5: 2050313X17718100. doi:10.1177/2050313X17718100. PMC 5528920. PMID 28835821.
  6. 6.0 6.1 Dogra S, Jindal R (2011). "Cutaneous manifestations of common liver diseases". J Clin Exp Hepatol. 1 (3): 177–84. doi:10.1016/S0973-6883(11)60235-1. PMC 3940632. PMID 25755383.
  7. 7.0 7.1 Shawcross DL, Wendon JA (2012). "The neurological manifestations of acute liver failure". Neurochem Int. 60 (7): 662–71. doi:10.1016/j.neuint.2011.10.006. PMID 22067133.
  8. Crippin JS, Gross JB, Lindor KD (1992). "Increased intracranial pressure and hepatic encephalopathy in chronic liver disease". Am J Gastroenterol. 87 (7): 879–82. PMID 1615943.
  9. Losowsky MS, Scott BB (1973). "Ascites and oedema in liver disease". Br Med J. 3 (5875): 336–8. PMC 1586440. PMID 4579401.
  10. Riley TR, Koch K (2003). "Characteristics of upper abdominal pain in those with chronic liver disease". Dig Dis Sci. 48 (10): 1914–8. PMID 14627332.
  11. McCormick PA, Nolan N (2004). "Palpable epigastric liver as a physical sign of cirrhosis: a prospective study". Eur J Gastroenterol Hepatol. 16 (12): 1331–4. PMID 15618841.
  12. Salam M, Matherly S, Farooq IS, Stravitz RT, Sterling RK, Sanyal AJ; et al. (2012). "Modified-orientation log to assess hepatic encephalopathy". Aliment Pharmacol Ther. 35 (8): 913–20. doi:10.1111/j.1365-2036.2012.05038.x. PMC 3616137. PMID 22348593.
  13. 13.0 13.1 Nabi E, Bajaj JS (2014). "Useful tests for hepatic encephalopathy in clinical practice". Curr Gastroenterol Rep. 16 (1): 362. doi:10.1007/s11894-013-0362-0. PMC 3918211. PMID 24357348.
  14. Rahimi RS, Elliott AC, Rockey DC (2013). "Altered mental status in cirrhosis: etiologies and outcomes". J Investig Med. 61 (4): 695–700. doi:10.2310/JIM.0b013e318289e254. PMID 23474970.
  15. ADAMS RD, FOLEY JM (1953). "The neurological disorder associated with liver disease". Res Publ Assoc Res Nerv Ment Dis. 32: 198–237. PMID 13134644.
  16. Djiambou-Nganjeu H (2017). "Hepatic Encephalopathy in Liver Cirrhosis". J Transl Int Med. 5 (1): 64–67. doi:10.1515/jtim-2017-0013. PMC 5490964. PMID 28680841.

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