Vital signs are reviewed for fever and signs of systemic toxicity (eg, hypotension, tachycardia).
General appearance is noted, particularly for cachexia and lethargy.
Head and neck examination includes inspection of the sclerae and tongue for icterus and the eyes for Kayser-Fleischer rings (best seen with slit lamp). Mild jaundice is best seen by examining the sclerae in natural light; it is usually detectable when serum bilirubin reaches 2 to 2.5 mg/dL (34 to 43 micromol/L). Breath odor should be noted (eg, for fetor hepaticus).
The abdomen is inspected for collateral vasculature, ascites, and surgical scars. The liver is palpated for hepatomegaly, masses, nodularity, and tenderness. The spleen is palpated for splenomegaly. The abdomen is examined for umbilical hernia, shifting dullness, fluid wave, masses, and tenderness. The rectum is examined for gross or occult blood.
Men are checked for testicular atrophy and gynecomastia.
The upper extremities are examined for Dupuytren contractures.
Neurologic examination includes mental status assessment and evaluation for asterixis (a characteristic flapping tremor of the hands).
The skin is examined for jaundice, palmar erythema, needle tracks, vascular spiders, excoriations, xanthomas (consistent with primary biliary cholangitis), paucity of axillary and pubic hair, hyperpigmentation, ecchymoses, petechiae, and purpura.