Hepatopulmonary syndrome physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for liver disease findings such as jaundice, palmar erythema, spider angiomata, gynaecomastia ,abdominal distension, caput medusae, splenomegaly either with or without sign and symptoms of hypoxemia such as cyanosis and clubbing.The presence of platypnea on physical examination is highly suggestive of hepatopulmonary syndrome.
Physical Examination
Physical examination of patients with hepatopulmonary syndrome is usually remarkable for liver disease findings such as jaundice, palmar erythema, spider angiomata, gynaecomastia ,abdominal distension, caput medusae, splenomegaly either with or without sign and symptoms of hypoxemia such as cyanosis and clubbing.The presence of platypnea on physical examination is highly suggestive of hepatopulmonary syndrome.
Appearance of the Patient
- Patients with hepatopulmonary syndrome may appear either normal, cyanotic, jaundiced, or ill, depend on the severity of their liver disease and HPS stage.
Vital Signs
- Platypnea (symptom)
- Orthodeoxia (sign), a drop of 4mmHg in PaO2 or, 5% in saturation when moving from the supine to the standing position.
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Skin
- Skin examination of patients with hepatopulmonary syndrome moight reveal, spider angiomata . (likelihood of HPS 21%).
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HEENT
- HEENT examination of patients with hepatopulmonary syndrome might be either normal, show sign and symptoms of hypoxemia such as cyanotic mucosal membranes, or findings of liver disease such as:
- Thinning of hair on the scalp due to hyperestrogenism
- Kayser-Fleischer rings in patients with Wilson's disease[1]
- Fetor hepaticus
Neck
- Neck examination of patients with hepatopulmonary syndrome is usually normal.
- Parotid gland enlargement might e present as a cirrhosis related finding.
- The following might be present in the differential diagnosis of HPS but neither role out nor role in HPS diagnosis.
Lungs
- Pulmonary examination of patients with hepatopulmonary syndrome might be normal.
- Platypnea
- Orthodeoxia
OR
- Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
- Rhonchi
- Vesicular breath sounds OR distant breath sounds
Heart
- Cardiovascular examination of patients with hepatopulmonary syndrome is usually normal.
OR
- Chest tenderness upon palpation
- PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
- Heave / thrill
- Friction rub
- S1
- S2
- S3
- S4
- Gallops
- A high/low grade early/late systolic murmur / diastolic murmur best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope
Abdomen
- Abdominal examination of patients with hepatopulmonary syndrome is usually normal.
OR
- Abdominal distension
- Abdominal tenderness in the right/left upper/lower abdominal quadrant
- Rebound tenderness (positive Blumberg sign)
- A palpable abdominal mass in the right/left upper/lower abdominal quadrant
- Guarding may be present
- Hepatomegaly / splenomegaly / hepatosplenomegaly
- Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
Back
- Back examination of patients with hepatopulmonary syndrome is usually normal.
OR
- Point tenderness over __ vertebrae (e.g. L3-L4)
- Sacral edema
- Costovertebral angle tenderness bilaterally/unilaterally
- Buffalo hump
Genitourinary
- Genitourinary examination of patients with hepatopulmonary syndrome is usually normal.
OR
- A pelvic/adnexal mass may be palpated
- Inflamed mucosa
- Clear/(color), foul-smelling/odorless penile/vaginal discharge
Neuromuscular
- Neuromuscular examination of patients with hepatopulmonary syndrome is usually normal.
OR
- Patient is usually oriented to persons, place, and time
- Altered mental status
- Glasgow coma scale is ___ / 15
- Clonus may be present
- Hyperreflexia / hyporeflexia / areflexia
- Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
- Muscle rigidity
- Proximal/distal muscle weakness unilaterally/bilaterally
- ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
- Unilateral/bilateral upper/lower extremity weakness
- Unilateral/bilateral sensory loss in the upper/lower extremity
- Positive straight leg raise test
- Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
- Positive/negative Trendelenburg sign
- Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
- Normal finger-to-nose test / Dysmetria
- Absent/present dysdiadochokinesia (palm tapping test)
Extremities
- Clubbing
- Cyanosis
- Palmar erythema (cirrhosis sign)
- Edema (due to decreased albumin production in a malfunctioning liver)
References
- ↑ Sridhar MS, Rangaraju A, Anbarasu K, Reddy SP, Daga S, Jayalakshmi S, Shaik B (2017). "Evaluation of Kayser-Fleischer ring in Wilson disease by anterior segment optical coherence tomography". Indian J Ophthalmol. 65 (5): 354–357. doi:10.4103/ijo.IJO_400_16. PMC 5565897. PMID 28573989.