Peripheral Stigmata of Liver Disease

1. Liver Failure - some exam findings to look for include:

• encephalopathy
• asterixis
• jaundice
• bruising
• fetor hepaticus
• muscle wasting
• clubbing (read more here)

2. High Estrogen states associated with liver disease, look for:

• palmar erythema
• spider nevi (these blanch)
• gynecomastia
• feminization of body hair
• testicular atrophy

3. For underlying clues as to the etiology of liver disease, look for:

• duputryen's contractures - alcohol
• keiser fleischer rings - Wilson's disease
• 'bronzed' complexion - iron overload syndromes (hemochromatosis)
• track marks - IV drug use, and perhaps underlying Hepatitis C.

4. Also look for signs of portal hypertension, which include:

• ascites and pedal edema (previously posted here and here)
• distended abdominal veins
• caput medusa
• splenomegaly

Below: duputrene's contracture, palmar erythema, and spider angioma

The Argyll Roberston Pupil

(Treponema pallidum pictured left)

Today we examined a patient for possible tertiary syphilis and looked specifically for an Argyll Roberston Pupil.

Accommodation Reflex: This is intact (CN II and III). There is pupillary constriction when an object is brought closer the patients face along with convergence of the eyes.

Pupillary Constriction to Light: This NOT intact (also CN II and III). When a light is shone into a patients eyes, there is no pupillary constriction.

We also examined a patient for aortic stenosis. You can read more about this here and here.

Lipids and the skin

1. Xanthelasma: cholestrol deposits under the skin, typically around the eye - often called xanthelasma palpebrarum. Usually yellowish/whitish and flat.

2. Eruptive xanthoma: can be pruritic, and may resolve over a few weeks. Often seen in patients with diabetes and hyperlipidemia. Pustular on an erythematous base.










3. Tendon xanthoma: classically a slowly appearing nodule on the extensor tendons of hands and feet.










4. Lipemia retinalis: Very high levels of triglycerides (>400 in the USA, >40 in the rest of the world). You can see a milky colouration to the retinal vessels.

A neat link from NEJM on lipemia retinalis over here.

Rheumatoid Arthritis: Some hand findings

On inspection remember to look for "SEADS" - swelling, erythema, atrophy, deformities, skin changes.










Wrist:

• Often has Radial deviation
• You may see a 'dinner fork' deformity at the wrist

Hand:

• Look for muscle atrophy in the interossious, thenar, and hypothenar regions
• Look and feel for Tendon nodules, and contractures

Fingers:

• Vasculitic nail changes: nail fold infarcts, periungual erythema
• Ulnar deviation of MCP's
• Swelling of the PIP's, the DIP's become involved later in the disease
• Swan Neck deformities (see photo above)
• Boutonniere deformitiy (see photo above)

Cranial Nerves III, IV, and VI

Interesting eye findings today:

Cranial Nerve III

• All extra ocular movements except those from the Superior Oblique (CN IV) and Lateral Rectus (CN VI).
• Innervates the Levator Palpebrae Superioris: this keeps your eyelid open. Many CN III lesions will result in ptosis.
• Efferent limb of the pupillary light reflex. Remember to look for a "direct" and then a "consensual" response to light.
• A Quick CN III Tip: Pupillary constriction is controlled by the outer fibers of CN III, and ocular movements/upper eyelids are controlled by the inner fibers. So lesions that compress the outer CN III fibers (eg. lesions like Posterior Communicating Artery Aneurysms) present initially with dilated pupils, while lesions affecting the inner portions of CN III (like infarction in diabetes) present with ptosis and a "down and out" position of the eye that spares the pupil.
  

Cranial Nerve IV

• Innervates the Superior Oblique muscle, which moves the eye "down and in". Lesions here result in difficulty looking down. Patients have trouble walking downs stairs.

Cranial Nerve VI

• Innervates the Lateral Rectus muscles, which moves the eye laterally.