Physical Examination

General Appearance: Signs of dehydration, septic appearance. Note whether the patient appears ill, well, or malnourished.

Vital Signs: Pulse, BP, respiratory rate, temperature (fever).

Skin: Jaundice, needle tracks, sclerotic veins from intravenous injections, urticaria, spider angiomas, bronze skin discoloration (hemochromatosis).

HEENT: Scleral icterus, sublingual jaundice, lymphadenopathy, Kayser-Fleischer rings (bronze corneal pigmentation, Wilson's disease).

Chest: Gynecomastia, Murphy's sign (inspiratory arrest with palpation of the right upper quadrant).

Abdomen: Scars, bowel sounds, right upper quadrant tenderness; liver span, hepatomegaly; liver margin texture (blunt, irregular, firm), splenomegaly (hepatitis) or hepatic atrophy (cirrhosis), ascites. Umbilical venous collaterals (Caput medusae). Courvoisier's sign (palpable nontender gallbladder with jaundice; pancreatic or biliary malignancy).

Genitourinary: Testicular atrophy.

Extremities: Joint tenderness, palmar erythema, Dupuytren's contracture (fibrotic palmar ridge).

Neuro: Disorientation, confusion, asterixis (flapping tremor when wrists are hyperextended, encephalopathy).

Rectal: Occult blood, hemorrhoids.

Labs: CBC with differential, LFTs, amylase, lipase, hepatitis serologies (hepatitis B surface antibody, hepatitis B surface antigen, hepatitis A IgM, hepatitis C antibody), antimitochondrial antibody (primary biliary cirrhosis), ANA, ceruloplasmin, urine copper (Wilson's disease), alpha-1-antitrypsin deficiency, drug screen, serum iron, TIBC, ferritin (hemochromatosis), liver biopsy.

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