Examination of the Liver Wash your hands & Introduce the exam to your patient Positioning & Draping · Position the patient so that their abdominal muscles are relaxed. Therefore, the patient: o is lying flat o has their arms at their sides o has a pillow under their head · Drape so that the abdomen is visible from the nipples to at least the Anterior Superior Iliac Spines (ASIS’s) Inspection · General -Look for: o masses, scars, and lesions (trauma) o atrophy/hypertrophy o discolouration o swelling o muscle bulk/symmetry o distended abdomen · Stigmata of liver disease -Look for: o jaundice -look at the sclera and frenulum o ascites -look for bulging flanks from the foot of the bed o everything else: § Hands · palmar erythema · Dupuytren's contracture · clubbing · Terry’s nails · thenar (thumb) wasting · leukonycia 1 © Michael Colapinto · asterixis o get the patient to cock their wrists back while holding their arms out straight o look for intermittent flapping § Estrogen dependent · spider nevi · gynecomastia · frontal balding · testicular atrophy § Liver dependent · jaundice & ascites (see above) · hepatomegaly or contracted liver · caput medusa · easy bruising & petechiae · edema · splenomegaly o bulging mass emerging from under the Left costal margin extending diagonally towards the Right Lower Quadrant (RLQ) · hemorrhoids & esophageal varices § Miscellaneous · fetor hepaticus · encephalopathy · temporal wasting Percussion (see Figure 1) · Liver span o percuss in the Right mid-clavicular line from "bottom up" & "top down" o from both directions, mark where dullness starts o normal liver span by percussion: § 10-12 cm (? ) § 8-10 cm (? ) 2 Palpation (see Figure 1) · begin in the RLQ, slightly superior to the inguinal ligament · proceed superiorly along the Right mid-clavicular line · direct the patient's breathing · attempt to palpate the liver edge during the inspiratory phase Figure 1: Direction of Percussion and Palpation of the Liver Auscultation · auscultate over the liver for bruits Special maneuvers · “The Scratch test” –aka Auscultory percussion (optional) o this test is used to determine the lower border of the liver o place the diaphragm of your stethoscope just superior to the costal margin in the Right mid-clavicular line 3 o starting from the RLQ in the mid-clavicular line and moving upwards toward the Right costal margin, lightly scratch the abdomen with your fingernail in a direction parallel to the Right costal margin o you should hear a scratching sound as your fingernail reaches the liver’s edge 4 .