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Difficulty: MediumPhysical Examination Findings

During morning rounds in the intensive care unit, a medical team evaluates a 56-year-old man who was admitted the previous night for altered mental status and significant abdominal distension. The patient's records indicate a history of chronic hepatitis C virus infection and severe, long-term alcohol use disorder. His spouse reports that he has become increasingly disoriented over the past week and his abdomen has rapidly swelled. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 102/60 mmHg, heart rate of 94/min, and respiratory rate of 16/min. The attending physician suspects decompensated liver cirrhosis with acute complications. Which of the following physical examination findings are expected in this patient? (Select all that apply)

  1. Dullness to percussion in the lateral abdomen that shifts when the patient rolls to a lateral decubitus positionAnswer
  2. B
    A sudden cessation of inspiration during deep palpation of the right upper quadrant
  3. Central red vascular lesions with radiating capillary branches on the upper chest that blanch upon pressureAnswer
  4. D
    A rhythmic, 4- to 6-Hz resting tremor of the hands that diminishes with voluntary, purposeful movement
  5. Brief, nonrhythmic, downward lapses of the outstretched, dorsiflexed handsAnswer

Answer

The correct findings are shifting dullness in the lateral abdomen, central red vascular lesions that blanch upon pressure (spider angiomata), and brief, nonrhythmic downward lapses of the outstretched hands (asterixis).
The patient's presentation is classic for decompensated liver cirrhosis with portal hypertension and hepatic encephalopathy. In this state, expected physical examination findings include signs of fluid accumulation such as ascites (demonstrated by shifting dullness), cutaneous stigmata of liver disease such as spider angiomata (caused by altered estrogen metabolism), and signs of metabolic neurotoxicity such as asterixis (brief, nonrhythmic lapses of outstretched hands due to impaired ammonia clearance).

Step-by-Step Solution

1
Analyze the patient's clinical presentation and history.
The patient has a history of chronic hepatitis C and alcohol abuse, presenting with altered mental status and abdominal swelling.
Identifying the underlying risk factors confirms a high likelihood of chronic liver disease (cirrhosis) presenting with acute decompensation.
2
Correlate the symptoms with specific pathophysiologic complications of cirrhosis.
Abdominal swelling suggests ascites resulting from portal hypertension. Altered mental status in this context suggests hepatic encephalopathy due to impaired toxin clearance.
Linking symptoms to their underlying mechanisms guides the expectation of specific physical examination signs.
3
Evaluate each physical examination description to identify those that match the complications of decompensated cirrhosis.
Shifting dullness confirms ascites; spider angiomata reflect chronic liver dysfunction (hyperestrinism); asterixis is the hallmark of hepatic encephalopathy.
Standardized board questions often test the recognition of eponymous or classic clinical signs through their precise physical descriptions rather than their names.

Key Concept

Physical stigmata of decompensated liver cirrhosis and portal hypertension include shifting dullness (ascites), asterixis (hepatic encephalopathy), and spider angiomata (hyperestrinism).
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Physical Examination Findings

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