Abdomen 4
Description
The patient was a middle-aged
man lying in bed. He appeared drowsy. He was tall and well built. He looked
deeply jaundiced.
On examination of his head, his
sclera were deeply icteric, there were multiple telangiectasiae over his face,
he was unshaven but beard growth appeared sparse, he had bilateral parotid
enlargement.
On examination of his hands,
there was no clubbing; there was palmar erythema, bilateral Dupuytren’s
contracture and a flapping tremor.
There was no gross abnormality
on brief inspection of the anterior aspect of his neck.
On examination of his chest, the
upper chest was covered with numerous telangiectasiae and spider naevi. Hair
growth on his chest was sparse and there was gynaecomastia.
On examination of his abdomen,
there was gross distension of the abdomen with eversion of the umbilicus. There
was no hair growth on the anterior abdominal wall and pubic hair was in the
female pattern. There were distended veins over the anterior abdominal wall. The
direction of blood flow in these vessels was away from the umbilicus.
There were no lumps palpable in
the abdomen and there was no organomegaly. There was flank dullness, horseshoe
dullness and shifting dullness but no fluid thrill.
No bruits, no venous hum.
Analysis
♥
The patient is drowsy. Drowsiness may be due to many causes
(See ACES for PACES Page 456) in the context of the abdominal station
and in a patient who is jaundiced one should consider portosystemic
encephalopathy (See ACES for PACES Page 292)
ª
Jaundice may be due to a number of causes
(See ACES for PACES Page 291) but with evidence of portosystemic
encephalopathy, the likelihood is that this is hepatocellular jaundice.
¨
Deep icterus confirms our impression of hepatocellular failure
(See ACES for PACES Page 294,305)
§
Decreased beard growth gives further evidence in favour of
hepatocellular failure (See ACES for PACES Page 295)
♥
Parotid enlargement suggests the cause of liver disease is alcohol
abuse (See ACES for PACES Page 296, 306)
ª
Palmar erythema is further evidence in favour of hepatocellular
failure (See ACES for PACES Page 298, 305)
¨
Dupuytren’s contracture would suggest the cause of the liver
disease is alcohol abuse (See ACES for PACES Page
298, 306)
§
Flapping tremor adds further weight to our impression that the
patient has portosystemic encephalopathy (See ACES
for PACES Page 298,446)
♥
Telangiectasiae, spider naevi, reduced hair on the chest and
gynaecomastia all lend further weight to our impression that this patient has
chronic hepatocellular failure (See ACES for PACES
Page 299,300,305)
ª
Distension of the abdomen in the context of the clinical features
we have already demonstrated would suggest the patient has ascites
(See ACES for PACES Page 300)
¨
Distended veins would blood flow away from the umbilicus pints to
portal hypertension (See ACES for PACES Page 302)
§
Demonstration of flank dullness, horseshoe dullness and shifting
dullness adds further weight to our impression that the patient has ascites
(See ACES for PACES Page 307)
♥
We have demonstrated that the patient has features of chronic
hepatocellular failure and features of portal hypertension. Therefore the
patient has clinical evidence of cirrhosis of the liver
(See ACES for PACES Page 305)
Diagnosis
ª
Cirrhosis of the liver
¨
Decompensated hepatocellular function
§
Portosystemic encephalopathy
♥
Aetiology most likely alcohol abuse
