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Cardiovascular System (CVS) - Complete History & Examination

For MD Medicine Students

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PART I: CVS HISTORY TAKING

1. Introduction & Patient Identification

• Name, age, sex, occupation, domicile
• Referred by / presenting complaints (in patient's own words)
• Duration of each complaint

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2. Chief Complaints - The "Cardinal Symptoms" of Heart Disease

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3. History of Presenting Complaints (SOCRATES for each symptom)

A. CHEST PAIN

• Site: Central, retrosternal, left chest, epigastric
• Onset: Sudden vs. gradual; at rest vs. exertion
• Character:
  • Squeezing/crushing/pressure-like = ischaemic (angina/ACS)
  • Sharp, pleuritic, worse lying flat, relieved sitting forward = pericarditis
  • Tearing/ripping, radiating to back = aortic dissection
  • Burning, epigastric = GERD (differential)
• Radiation: To left arm, jaw, neck, back (aortic dissection)
• Associated symptoms: Sweating, nausea, vomiting, dyspnea, syncope
• Time: Duration (minutes = angina; >20 min = ACS; constant = pericarditis)
• Exacerbating/Relieving: Exertion, emotion, cold, heavy meals; relief with nitrates (angina), sitting forward (pericarditis)
• Severity: 1-10 scale

B. DYSPNEA

• Type: Exertional dyspnea (ED), orthopnea, paroxysmal nocturnal dyspnea (PND), dyspnea at rest
• NYHA Functional Classification for exertional dyspnea:
  • Class I: No symptoms with ordinary activity
  • Class II: Slight limitation; symptoms with moderate exertion
  • Class III: Marked limitation; symptoms with minimal exertion, comfortable at rest
  • Class IV: Symptoms at rest or with any activity
• Orthopnea: Number of pillows used (2-pillow, 3-pillow orthopnea); due to redistribution of fluid from legs to pulmonary circulation when lying flat
• PND: Awakens patient from sleep after 1-2 hours; relieved by sitting up or standing; caused by pulmonary oedema
• Cardiac vs. pulmonary dyspnea: Ask about wheeze, productive cough, history of smoking, occupational exposure

C. PALPITATIONS

• Character: Fast, slow, irregular, "fluttering," "thudding"
• Onset: Sudden/gradual, at rest/exertion
• Associated: Presyncope, chest pain, dyspnea
• Precipitating: Coffee, alcohol, thyroid disease, anxiety
• Duration and termination: Spontaneous, Valsalva manoeuvre
• Ask about: Prior ECG, ablation, medications

D. SYNCOPE

• Pre-syncope vs. true loss of consciousness
• Postural (orthostatic hypotension), exertional (AS, HOCM - high risk!), situational (micturition, cough, defaecation - vasovagal)
• Warning (prodrome): Lightheadedness, sweating = vasovagal vs. no warning = Stokes-Adams (complete heart block, VT)
• Recovery: Rapid = vasovagal; prolonged confusion = seizure
• Tongue bite, incontinence = suggest seizure

E. OEDEMA

• Location: Dependent (bilateral ankle/leg = cardiac), unilateral = DVT/venous insufficiency
• Duration, progression
• Worse at end of day, improved after recumbency (cardiac)
• Ask about ascites, facial puffiness (nephrotic syndrome differential)
• Associated: SOB, abdominal distension (ascites with RHF)

F. COUGH & HAEMOPTYSIS

• Dry nocturnal cough = LV failure, ACE inhibitor side effect
• Frothy pink sputum = acute pulmonary oedema
• Haemoptysis = mitral stenosis, PE, Eisenmenger syndrome

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4. Past Medical History (PMH)

• Previous cardiac events: MI, heart failure, cardiac surgery, PCI/CABG, pacemaker/ICD
• Hypertension (duration, control, medications)
• Diabetes mellitus
• Hyperlipidaemia
• Rheumatic fever (important for valvular disease, especially MS)
• Congenital heart disease
• Stroke/TIA
• Peripheral vascular disease
• Renal disease
• Thyroid disease
• Previous ECG/Echo/angiogram findings

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5. Drug History

• Current cardiac medications: antihypertensives, anticoagulants, antiplatelets, statins, diuretics, nitrates, digoxin, antiarrhythmics
• Cardiotoxic drugs: Doxorubicin, trastuzumab, clozapine
• Drugs causing QT prolongation: antipsychotics, macrolides, fluoroquinolones
• NSAIDs (worsen heart failure, increase BP)
• OCP (increases thrombotic risk)
• Over-the-counter/herbal medications
• Allergies: Drug name, type of reaction

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6. Family History

• First-degree relatives with:
  • Premature coronary artery disease (men <55 yrs, women <65 yrs)
  • Sudden cardiac death (especially at young age - suggests HOCM, channelopathies: LQTS, Brugada)
  • Hypertension, diabetes, hyperlipidaemia
  • Cardiomyopathy (familial dilated, HOCM)
  • Marfan syndrome, connective tissue disorders
  • Congenital heart disease

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7. Social History

• Smoking: Pack-years, current or ex-smoker, passive exposure
• Alcohol: Units per week (alcoholic cardiomyopathy, AF trigger, hypertension)
• Recreational drugs: Cocaine (coronary spasm, MI, dissection), amphetamines, anabolic steroids
• Diet: Saturated fat, salt intake
• Exercise: Level of physical activity (important for functional assessment)
• Occupation: Physical demands, occupational toxin exposure, stress
• Travel history: Endemic areas (Chagas disease, infective endocarditis risk)
• Socioeconomic: Affects access to care, medication compliance

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8. Systems Review (relevant to CVS)

• Respiratory: Wheeze, chronic cough, sputum
• GI: Nausea, vomiting (inferior MI), abdominal pain (mesenteric ischaemia, hepatomegaly)
• Renal: Oliguria, haematuria (endocarditis), nocturia (HF)
• Neurological: TIA, stroke, visual disturbances (emboli)
• Musculoskeletal: Joint pains (rheumatic fever, reactive arthritis)
• Endocrine: Sweating, heat intolerance, weight change (thyroid), polyuria/polydipsia (diabetes)

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PART II: CVS PHYSICAL EXAMINATION

STEP 1: GENERAL EXAMINATION (Begins before laying hands on the patient)

A. General Appearance

• Comfortable at rest vs. in distress, breathless, diaphoretic
• State of nutrition: Cachectic (cardiac cachexia in advanced HF), obese (metabolic syndrome)
• Position: Sitting upright/leaning forward (pericarditis), unable to lie flat (orthopnea)
• Cheyne-Stokes respiration (advanced heart failure, low cardiac output)
• Pallor, cyanosis (central vs. peripheral), jaundice

B. Skin & Nails

• Central cyanosis: Tongue + mucous membranes; significant right-to-left shunt (congenital HD, Eisenmenger)
• Peripheral cyanosis (acrocyanosis): Fingers/toes only; low flow states - HF, shock, peripheral vascular disease
• Differential cyanosis: Lower limbs only (PDA + pulmonary hypertension, right-to-left shunt at great vessel level)
• Clubbing: Chronic cyanotic congenital HD (ToF, TGA), infective endocarditis, lung disease
• Splinter haemorrhages: Infective endocarditis (also trauma)
• Osler's nodes: Painful red nodules on finger pads - infective endocarditis
• Janeway lesions: Painless haemorrhagic macules on palms/soles - infective endocarditis
• Koilonychia: Spoon-shaped nails (iron deficiency, high output failure)
• Xanthelasma, xanthomas: Hyperlipidaemia; tendon xanthomas = familial hypercholesterolaemia
• Arcus cornealis (arcus senilis): <45 yrs suggests dyslipidaemia
• Malar flush: Mitral stenosis (MS facies), scleroderma
• Petechiae: Infective endocarditis

C. Facies

• Malar flush (MS)
• Exophthalmos + lid retraction: Hyperthyroidism
• Expressionless face + ptosis: Myotonic dystrophy (associated with AV block, arrhythmia)
• Down syndrome facies, Turner's syndrome, Marfan habitus

D. Skeletal/Dysmorphic Features

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STEP 2: VITAL SIGNS

A. Heart Rate

• Normal: 60-100 bpm
• Method: Radial pulse for 60 seconds
• Rate: Bradycardia (<60) or tachycardia (>100)
• Character and rhythm

B. Blood Pressure

• Measure both arms: >10 mmHg difference = subclavian artery stenosis, aortic dissection, or coarctation
• Measure both arms AND at least one leg when coarctation of aorta suspected (BP higher in arms than legs in CoA)
• Pulsus paradoxus: >10 mmHg fall in SBP during inspiration = cardiac tamponade, severe asthma, constrictive pericarditis
• Hypertensive urgency/emergency assessment
• Wide pulse pressure: Aortic regurgitation, hyperthyroidism, severe anaemia, AV fistula
• Narrow pulse pressure: Aortic stenosis, cardiac tamponade, constrictive pericarditis, severe LV dysfunction

C. Respiratory Rate

• Tachypnoea (>20/min): Heart failure, pulmonary oedema

D. Temperature

• Fever: Infective endocarditis, pericarditis, myocarditis, acute rheumatic fever

E. Peripheral O2 Saturation (SpO2)

• <94% warrants further investigation

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STEP 3: THE HANDS, FACE, NECK (Peripheral Examination)

A. Hands

• Clubbing (grade I-IV)
• Splinter haemorrhages, Osler's nodes, Janeway lesions
• Peripheral cyanosis, capillary refill time
• Tremor (thyrotoxicosis)
• Temperature: Cold peripheries = low cardiac output

B. Eyes

• Xanthelasma (hyperlipidaemia)
• Corneal arcus
• Kayser-Fleischer rings (Wilson's disease - cardiomyopathy)
• Roth spots (infective endocarditis)
• Retinal artery occlusion (embolism from LA thrombus or myxoma)
• Subconjunctival haemorrhage
• Exophthalmos (hyperthyroidism)

C. Mouth

• Dentition and oral hygiene (source of bacteraemia - endocarditis risk)
• High-arched palate (Marfan syndrome)
• Bifid uvula (Loeys-Dietz syndrome)
• Orange tonsils (Tangier disease)
• Telangiectasias on tongue/lips (Osler-Weber-Rendu syndrome - source of R-to-L shunt if pulmonary AVMs)
• Cyanotic tongue (central cyanosis)

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STEP 4: CAROTID PULSE

• Method: Palpate one side at a time, gentle pressure, below the angle of the jaw
• Character of the carotid pulse:

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STEP 5: JUGULAR VENOUS PRESSURE (JVP)

A. How to Assess JVP

1. Position patient at 30-45° (use 45° initially; adjust to visualise the meniscus)
2. Turn head slightly to the left to examine the right internal jugular vein (preferred - directly in line with SVC and RA)
3. Identify the venous pulsation just lateral to the sternocleidomastoid muscle
4. Measure the vertical height of the venous pulsation above the sternal angle of Louis
5. Normal = <4.5 cm above the sternal angle at 45°
6. The sternal angle is approximately 5 cm above the mid-right atrium, so total CVP (cmH2O) = height above sternal angle + 5 cm
7. If JVP is elevated, sit the patient fully upright with legs dangling to better assess the upper limit
8. If not visible at 30-45°, check at 60° or even 90° (sitting)

B. JVP Waveform Components

C. Abnormalities of JVP Waveform

D. Abdominojugular Reflux (Hepatojugular Reflux)

• Apply firm pressure over right upper quadrant (upper abdomen) for >15 seconds
• Positive = sustained rise in JVP >3 cm
• Indicates elevated pulmonary capillary wedge pressure >15 mmHg
• Assess at 10 seconds (allow abdominal muscle tensing to subside)
• Caution patient not to Valsalva during test

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STEP 6: PRECORDIAL EXAMINATION

A. INSPECTION

1. Chest shape: Barrel chest, pectus excavatum (compresses heart, can produce systolic murmur), pectus carinatum, kyphoscoliosis (cor pulmonale), asymmetry
2. Scars:
   • Midline sternotomy = CABG, valve surgery, congenital HD surgery
   • Left submammary/lateral thoracotomy = mitral valvotomy (old closed commissurotomy), BT shunt
   • Right infraclavicular scar = pacemaker/ICD implant
3. Visible pulsations:
   • Apex beat (visible in ~50% of normals)
   • Visible left parasternal heave = RV hypertrophy
   • Epigastric pulsation = aortic aneurysm, right ventricular enlargement
   • Pulsatile neck veins (see JVP section)
4. Dilated veins on chest wall: SVC obstruction, caval obstruction

B. PALPATION

• Location: Normally in the 5th intercostal space, midclavicular line (MCL)
• Character:

  Type	Description	Association
  Normal	Tapping, localised, <2.5 cm	Normal
  Heaving (sustained, forceful)	Hyperdynamic, displaced, lifts finger	LVH (pressure overload: AS, hypertension)
  Hyperdynamic (thrusting, volume-loaded)	Vigorous, displaced laterally	Volume overload: AR, MR, VSD
  Tapping	Palpable S1, sharp	Mitral stenosis (loud S1 palpable)
  Diffuse/dyskinetic	Broad, unsustained, multiple areas	LV aneurysm, dilated cardiomyopathy
  Double impulse	Two distinct pulsations	HOCM (systolic + atrial), LV aneurysm
  Absent	Not palpable	Obesity, emphysema, pericardial effusion, dextrocardia

• Displacement: Lateral (LV dilatation/LVH), downward, mediastinal shift

• Place heel of hand over left parasternal area (2nd-4th ICS)
• Sustained heave lifting the hand = right ventricular hypertrophy/overload (pulmonary hypertension, pulmonary stenosis, severe MS, large ASD)

• A palpable murmur (grade 4+ murmur): Systolic thrill = AS, VSD, PS; Diastolic thrill = MS (rare), AR
• Location as per murmur site

• Palpable S1 (tapping apex) = MS
• Palpable P2 in pulmonary area = pulmonary hypertension

• Limited use in cardiac exam
• May help delineate cardiac borders
• Shifting of cardiac border to the right (dextrocardia - confirmed by apex beat)
• Dull left costophrenic angle (pleural effusion in heart failure)

C. AUSCULTATION

• Diaphragm (high-frequency): S1, S2, AR, MR, pericardial rub, ejection clicks
• Bell (low-frequency, light pressure): S3, S4, MS (mitral diastolic murmur)

1. Aortic area: 2nd right intercostal space, right sternal border (2RICS)
2. Pulmonary area: 2nd left intercostal space, left sternal border (2LICS)
3. Erb's point (left 3rd ICS): AR often best heard here in leaning-forward position
4. Tricuspid area: Lower left sternal border (4-5th ICS, LLSB)
5. Mitral area (Apex): 5th ICS, MCL - left lateral decubitus position for low-frequency sounds

Heart Sounds

• Closure of mitral (M1) and tricuspid (T1) valves at onset of systole; M1 precedes T1
• Heard best at the apex
• Loud S1: MS (restricted leaflet excursion, mobile but not closing fully until high LA pressure), hyperdynamic states (fever, anaemia, thyrotoxicosis), short PR interval
• Soft S1: LV dysfunction, calcified/immobile MV, prolonged PR interval (1° AV block), MR
• Variable S1: AF, complete AV dissociation

• Closure of aortic (A2) and pulmonary (P2) valves; A2 precedes P2
• Heard best at base (2nd ICS)
• Splitting of S2:

  Type	Behaviour	Cause
  Physiological splitting	Widens on inspiration, closes on expiration	Normal
  Wide splitting	Wide but moves with respiration	RBBB, pulmonary stenosis, ASD
  Fixed splitting	Wide, does NOT change with respiration	ASD (classic)
  Paradoxical (reversed) splitting	Narrows on inspiration	LBBB, severe AS, HOCM
  Absent P2	P2 not audible	Severe PS, pulmonary atresia
  Loud P2	Accentuated, may be palpable	Pulmonary hypertension
  Loud A2	Systemic hypertension

• Aortic ejection click: 2RICS, does NOT vary with respiration - aortic stenosis, bicuspid aortic valve, aortic root dilatation
• Pulmonary ejection click: 2LICS, disappears on inspiration - pulmonary valve stenosis

Heart Murmurs

• PDA: "Machinery murmur" - left infraclavicular area
• Ruptured sinus of Valsalva aneurysm
• AV fistula
• Coarctation of aorta (also intercostal/back)

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STEP 7: LUNG EXAMINATION (Cardiovascular Assessment)

• Bibasal crepitations (fine): Pulmonary oedema / LV failure
• Wheeze: Cardiac asthma (bronchoconstriction from interstitial oedema)
• Dullness at lung bases: Pleural effusion (LV failure - typically bilateral; unilateral right > left)
• Reduced air entry: Pleural effusion

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STEP 8: ABDOMINAL EXAMINATION

• Hepatomegaly: Tender, smooth liver edge = congestive hepatopathy (RHF)
  • Pulsatile hepatomegaly: Tricuspid regurgitation (systolic expansion)
• Hepatojugular reflux: Press on RUQ; JVP rises = elevated PCWP, RHF
• Ascites: Congestive cardiac failure (right-sided), constrictive pericarditis
• Splenomegaly: Infective endocarditis (septic emboli), LV failure (portal hypertension)
• Aortic pulsation: Abdominal aortic aneurysm (pulsatile, expansile mass in midline)
• Arterial bruits: Renal artery bruits (renovascular hypertension), iliac bruit

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STEP 9: PERIPHERAL VASCULAR EXAMINATION

• Peripheral pulses: Radial, brachial, carotid, femoral, popliteal, posterior tibial, dorsalis pedis - note presence, character, symmetry
• Radio-femoral delay: Coarctation of the aorta (femoral pulse delayed relative to radial)
• Radio-radial inequality: Subclavian artery stenosis, aortic dissection
• Absent peripheral pulses: PVD, embolism
• Ankle-Brachial Index (ABI): <0.9 = peripheral arterial disease
• Varicosities, venous insufficiency, DVT signs
• Peripheral oedema: Pitting/non-pitting; bilateral (cardiac, hypoalbuminaemic) vs. unilateral (DVT, lymphoedema)
  • Note: Pitting oedema also caused by dihydropyridine calcium channel blockers
  • Homans' sign (dorsiflexion calf pain) - neither sensitive nor specific for DVT

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STEP 10: COMPLETING THE EXAMINATION

• Thank and cover the patient
• State: "To complete my examination I would also like to:
  • Measure blood pressure in both arms (and legs if coarctation suspected)
  • Perform fundoscopy (hypertensive/diabetic retinopathy, Roth spots)
  • Check urine dipstick (haematuria in endocarditis, proteinuria in renal disease)
  • Review 12-lead ECG, chest X-ray, echocardiogram
  • Perform pulse oximetry
  • Examine the back (kyphoscoliosis, sacral oedema in bedridden patients)
  • Sacral oedema: Always check in bedridden/immobile patients"

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PART III: SUMMARY TABLES

NYHA vs. CCS vs. Specific Activity Scale

Signs That Indicate Specific Conditions

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Sources

• Harrison's Principles of Internal Medicine, 22nd Edition (2025), McGraw Hill - Chapter 246: Physical Examination of the Cardiovascular System, pp. 1902-1909
• Goldman-Cecil Medicine, International Edition - Chapter 39: Physical Examination for Detection of Signs of Cardiovascular Disease, pp. 391-393
• Fuster and Hurst's The Heart, 15th Edition - Clinical Cardiovascular Examination
• Braunwald's Heart Disease, 2-Volume Set, A Textbook of Cardiovascular Medicine

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Chronic Liver Disease (CLD) with Ascites

Complete History & Examination for MD Medicine Students

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PART I: HISTORY TAKING

1. Patient Identification

• Name, age, sex, occupation, address, religion (alcohol prohibition relevant), marital status
• Referred from / Source of history (patient / relative - encephalopathy may impair recall)

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2. Chief Complaints (in order of duration)

1. Abdominal distension / swelling (ascites) - onset, duration, progression
2. Jaundice - eyes/skin yellowing
3. Swelling of legs (bilateral pedal oedema)
4. Haematemesis / melaena (variceal bleeding)
5. Altered consciousness / drowsiness / confusion (hepatic encephalopathy)
6. Loss of appetite, weight loss, easy fatigability
7. Abdominal pain / discomfort
8. Abdominal pain + fever (spontaneous bacterial peritonitis - SBP)
9. Decreased urine output (hepatorenal syndrome)

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3. History of Presenting Complaints

A. ASCITES (Abdominal Distension)

• Onset: Sudden vs. gradual; duration (weeks/months/years)
• Progression: Stable, slowly progressive, or rapidly increasing
• Extent: Only abdomen, or also scrotal/penile oedema (grade 3)
• Grading of ascites (International Ascites Club - Sleisenger & Fordtran, p. 1799):

  Grade	Description
  Grade 1	Mild - only detectable by ultrasound
  Grade 2	Moderate - detectable by physical examination, moderate abdominal distension
  Grade 3	Large/tense - marked abdominal distension

• Recurrent ascites: ≥3 episodes per year despite treatment = refractory ascites
• Associated symptoms: Breathlessness (diaphragm elevation/hepatic hydrothorax), difficulty eating (early satiety)
• Treatment: Diuretics, paracentesis - any prior episodes treated?

B. JAUNDICE

• Onset: Sudden (acute hepatitis, biliary obstruction) vs. gradual (CLD)
• Colour of urine (dark = conjugated hyperbilirubinaemia), stool colour (pale = obstructive jaundice)
• Associated: Pruritus (cholestatic), abdominal pain (biliary), fever (cholangitis/hepatitis)
• Progression: Deepening or improving
• Prior episodes?

C. HAEMATEMESIS / MELAENA (Variceal Bleeding)

• Number of episodes, quantity of blood, colour (bright red = arterial/oesophageal variceal; coffee grounds = gastric)
• Melaena: Black tarry stool = upper GI bleeding
• Associated: Pre-syncope, tachycardia, hypotension
• Prior endoscopy/banding/sclerotherapy?
• Note: "Upper GI bleeding in patients with cirrhosis, often from esophageal varices, carries a 10-15% mortality" (Rosen's EM, p. 2502)

D. HEPATIC ENCEPHALOPATHY

• Changes in sleep pattern (early feature - sleep reversal), personality changes, irritability
• Confusion, disorientation, drowsiness, coma (progression)
• Precipitating factors (see below)
• Grade of encephalopathy at presentation
• West-Haven Criteria for HE Grading:

  Grade	Features
  Grade 0 (minimal HE)	No clinical symptoms; only detected on psychometric testing
  Grade I	Mild confusion, sleep disturbance, mood changes, slurred speech
  Grade II	Drowsiness, disorientation, asterixis (flapping tremor), inappropriate behaviour
  Grade III	Somnolence but arousable, gross disorientation, asterixis prominent
  Grade IV	Coma; no response to verbal or painful stimuli

• Common precipitants (TIPS mnemonic):
  • Infections (SBP, UTI, pneumonia)
  • GI bleed (increased protein/ammonia load)
  • Constipation
  • Electrolyte imbalance (hypokalemia, alkalosis - diuretic-induced)
  • Sedative/opiate drugs
  • Dehydration
  • Hepatocellular carcinoma development
  • Renal failure (hepatorenal syndrome)
  • Large protein meal
  • TIPS procedure itself (portosystemic shunting)

E. FEVER / ABDOMINAL PAIN (Suspicious of SBP)

• Fever, rigors, diffuse abdominal pain = SBP until proven otherwise
• "SBP is an acute infection of ascitic fluid that should be considered in any patient with ascites and abdominal pain, fever, or unexplained clinical deterioration" (Rosen's EM, p. 2526)
• Spontaneous vs. triggered, antibiotic use

F. DECREASED URINE OUTPUT (Hepatorenal Syndrome)

• Oliguria/anuria in the background of CLD with ascites = hepatorenal syndrome
• "Hepatorenal syndrome is heralded by an increasing creatinine level in the setting of liver failure, and is associated with a high rate of mortality" (Rosen's EM, p. 2510)
• Aggravated by: Diuretic overuse, NSAIDs, contrast agents, ACE inhibitors/ARBs

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4. Aetiology-Directed History ("Why does this patient have CLD?")

A. Alcohol

• Duration, quantity (units/week or standard drinks/day), type of alcohol
• Last drink taken
• CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) - ≥2 positive = harmful use
• Alcoholic hepatitis episodes
• Liver biopsy? Social/occupational impact of alcohol

B. Viral Hepatitis

• Hepatitis B: Vaccination history, IV drug use, blood transfusion, sexual contacts (esp. MSM), vertical transmission (born to HBsAg+ mother), body piercing/tattooing, shared razors/needles
• Hepatitis C: IV drug use (most common in West), blood transfusion (before 1992), needlestick injury, tattoos, sexual contacts, vertical transmission
• Hepatitis D: Only with HBV; ask in HBV patients
• Hepatitis E: Travel to endemic areas (India, SE Asia, Africa), contaminated water, pregnancy

C. Non-Alcoholic Fatty Liver Disease (NAFLD/MASH)

• Metabolic risk factors: Obesity (BMI, waist circumference), type 2 diabetes, dyslipidaemia, hypertension, metabolic syndrome
• Sedentary lifestyle, high-calorie diet

D. Autoimmune

• Autoimmune hepatitis: Young/middle-aged woman, other autoimmune diseases (thyroid, IBD, RA, vitiligo), fatigue, joint pains
• Primary Biliary Cholangitis (PBC): Middle-aged woman, pruritus, fatigue, xanthelasma, sicca syndrome (dry eyes/mouth)
• Primary Sclerosing Cholangitis (PSC): Young man, associated IBD (UC >50% of cases), episodic jaundice, pruritus

E. Hereditary/Metabolic

• Haemochromatosis: Family history, joint pains, diabetes, skin bronzing, impotence (males), cardiomyopathy
• Wilson's disease: Young age (<40 yrs), neuropsychiatric symptoms, Kayser-Fleischer rings, family history
• Alpha-1 antitrypsin deficiency: Early-onset emphysema, family history

F. Drug-Induced Liver Injury (DILI)

• Methotrexate (chronic use), amiodarone, isoniazid, valproate, herbal medicines, supplement use
• Paracetamol overdose (acute on chronic)

G. Biliary Disease

• Gallstones, recurrent cholangitis, biliary stricture
• Prior biliary surgery

H. Vascular

• Budd-Chiari syndrome: Hypercoagulable states (OCP, JAK2 mutation, nephrotic syndrome), hepatic vein thrombosis
• Congestive cardiac failure (cardiac cirrhosis): History of RHF, constrictive pericarditis

I. Cryptogenic

• All causes excluded = cryptogenic cirrhosis (often end-stage NAFLD)

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5. Past Medical History

• Prior episodes of hepatic decompensation: Jaundice, ascites, HE, variceal bleed
• Hospitalizations, paracenteses performed (number, volume drained)
• Prior liver biopsy and findings
• History of diabetes, hypertension, cardiovascular disease, thyroid disease
• Previous blood transfusions (hepatitis C risk)
• Abdominal surgeries
• Known malignancy (metastatic disease causing ascites)

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6. Drug History

• Diuretics: Spironolactone + furosemide (standard CLD ascites regimen)
• Beta-blockers (for portal hypertension/varices prophylaxis: propranolol, carvedilol)
• Lactulose (HE treatment/prevention)
• Rifaximin (HE prophylaxis/treatment)
• Antiviral medications: Tenofovir, entecavir (HBV), DAAs (HCV)
• NSAIDs, ACE inhibitors, ARBs: Contraindicated in decompensated cirrhosis/ascites - can precipitate AKI/HRS
• Anticoagulants (if Budd-Chiari/portal vein thrombosis)
• Hepatotoxic drugs to enquire about: Methotrexate, amiodarone, isoniazid, herbal preparations
• Vitamin K, albumin infusions
• Allergies

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7. Family History

• Liver disease (hereditary conditions: Haemochromatosis, Wilson's, Alpha-1-AT deficiency)
• Hepatitis B (vertical transmission)
• Alcoholism
• Malignancy (HCC, colon cancer - PSC association)
• Autoimmune conditions

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8. Social History

• Alcohol: Detailed quantification, type, duration (see above)
• Smoking: Pack-years (also risk factor for HCC)
• Recreational drugs: IV drug use (hepatitis B/C), cocaine/ecstasy (hepatotoxic)
• Occupation: Healthcare worker (HBV/HCV risk), chemical exposure (vinyl chloride, carbon tetrachloride - angiosarcoma), aflatoxin exposure
• Diet and nutrition: Protein intake (important - muscle wasting in cirrhosis; protein restriction now discouraged), salt intake
• Travel history: Endemic areas for hepatitis E, schistosomiasis (sub-Saharan Africa, Middle East - "clay pipestem fibrosis")
• Sexual history: Multiple partners, MSM (HBV risk)
• Socioeconomic: Housing, support network, compliance with treatment, ability for follow-up
• Religion: Muslim/Jewish/etc. (alcohol prohibition makes alcohol less likely)

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9. Systems Review (relevant to CLD)

• Pruritus (cholestasis - PBC, PSC, biliary obstruction)
• Weight loss, anorexia, muscle wasting
• Easy bruising/bleeding (coagulopathy, thrombocytopenia)
• Confusion, sleep disturbance (HE)
• Decreased libido, menstrual irregularity (in women), gynecomastia/testicular atrophy (men) - endocrine dysfunction
• Joint pains (autoimmune, haemochromatosis, PSC)
• Shortness of breath (hepatic hydrothorax, hepatopulmonary syndrome, portopulmonary hypertension)
• Haematochezia/rectal bleeding (haemorrhoids from portal hypertension)
• Abdominal pain (SBP, hepatoma)

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PART II: PHYSICAL EXAMINATION

STEP 1: GENERAL EXAMINATION

A. General Appearance

• Conscious, oriented, cooperative vs. drowsy/confused/encephalopathic?
• Nutritional status: Thin, emaciated, muscle wasting (temporal wasting, interosseous muscle wasting, quadriceps wasting) - despite enlarged abdomen; "skin and bone with a big belly" - cardiac cachexia or cirrhotic wasting
• Jaundice: Scleral icterus, skin yellowing (best seen in natural light, mucous membranes)
• Pallor: Conjunctival pallor (anaemia from bleeding/hypersplenism/nutritional deficiency)
• Cyanosis: Hepatopulmonary syndrome (right-to-left intrapulmonary shunting); peripheral cyanosis
• Oedema: Bilateral pedal oedema, scrotal/penile oedema visible
• Abdominal distension: Flanks full/bulging, shifted umbilicus, visible veins on abdomen
• Fetor hepaticus: Sweet, musty breath ("breath of the dead") - hallmark of hepatic encephalopathy; caused by dimethyl sulphide and mercaptans (volatile sulphur compounds) produced by gut bacteria from nitrogenous compounds bypassing the liver
• Flapping tremor (asterixis): Ask patient to hold arms outstretched with wrists dorsiflexed - observe for flapping movements (negative myoclonus: intermittent lapse in sustained posture due to brief loss of muscle tone); seen in grades II-III HE

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STEP 2: VITAL SIGNS

• Temperature: Fever (SBP, hepatitis, cholangitis, hepatocellular carcinoma)
• Pulse: Tachycardia (bleeding, infection, cardiac failure); bounding/high-volume pulse (hyperdynamic circulation in cirrhosis - high CO, low SVR); may be regular or irregular (AF common in alcoholic liver disease)
• Blood Pressure: Hypotension (sepsis/SBP, variceal haemorrhage, HRS), wide pulse pressure (hyperdynamic state)
• Respiratory Rate: Tachypnoea (hepatic hydrothorax, pulmonary complications, SBP)
• SpO2: Low in hepatopulmonary syndrome; check for positional oxygen desaturation (platypnoea-orthodeoxia = hypoxia worsens when sitting up - hepatopulmonary syndrome)

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STEP 3: HANDS

A. Nails

• Leuconychia (Terry's nails / white nails): Hypoalbuminaemia; white opacification of nails; "white nails (leukonychia)" (Bailey & Love, p. 1667) - a hallmark of chronic liver disease
• Clubbing: CLD (hepatopulmonary syndrome, biliary cirrhosis), also infective endocarditis, lung disease
• Koilonychia: Spoon-shaped nails (iron deficiency anaemia in CLD)
• Muehrcke's lines: Paired white horizontal lines (hypoalbuminaemia)
• Half-and-half nails (Lindsay's nails): Proximal white + distal brown (uraemia, also seen in CLD)
• Splinter haemorrhages: Infective endocarditis (also trauma)

B. Skin of Hands/Palms

• Palmar erythema: Reddening of the thenar and hypothenar eminences (sparing the central palm) - due to increased oestrogen from impaired hepatic metabolism; "palmar erythema" (Bailey & Love, p. 1666-1667)
• Dupuytren's contracture: Fibrosis of palmar fascia with flexion contracture of ring/little fingers; associated with alcoholic liver disease and alcohol use
• Palmar creases: Pale = anaemia

C. Tremor / Asterixis

• Coarse tremor of hands (alcohol withdrawal)
• Asterixis (flapping tremor): As described above - HE grade II onwards; also seen in uraemia, respiratory failure, drug toxicity (not specific to liver disease)
• Note: "The most useful clinical sign is a flapping tremor when [the arms are outstretched]" (Bailey & Love, p. 1672)

D. Wrist/Forearm

• Bruising: Coagulopathy (prolonged PT/INR)
• Peripheral muscle wasting (sarcopenia/cirrhotic myopathy)

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STEP 4: ARMS, UPPER LIMBS

• Spider naevi: Cutaneous vascular abnormalities (central arteriole with radiating vessels); blanch completely on pressure and refill from the centre outward; found in the distribution of superior vena cava (face, neck, arms, upper chest - above nipple line); >5 is significant; "spider naevi (cutaneous vascular abnormalities that blanch on pressure)" (Bailey & Love, p. 1666); due to excess oestrogen; increase in number with worsening liver function; also seen in pregnancy and thyrotoxicosis (physiological), but >5 above nipple line = pathological
• Bruising: Forearms, due to coagulopathy (low clotting factors) + thrombocytopenia (hypersplenism)
• Track marks: IV drug use (hepatitis B/C risk)
• Xanthomas: Hyperlipidaemia (PBC association)
• Hyperpigmentation: Haemochromatosis (bronze diabetes)

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STEP 5: HEAD AND FACE

A. Eyes

• Scleral icterus: Earliest visible sign of jaundice (bilirubin >2-3 mg/dL); examine in natural light
• Kayser-Fleischer rings: Gold-brown rings at the corneal periphery (Descemet's membrane) - Wilson's disease; best seen with slit-lamp; visible to naked eye in deep green-brown form
• Xanthelasma: Yellowish plaques around eyelids (PBC, hyperlipidaemia)
• Anaemia: Conjunctival pallor
• Parotid enlargement: Alcohol-related (bilateral parotid swelling = "chipmunk face" in alcoholism)

B. Mouth and Face

• Fetor hepaticus: Characteristic musty/sweet breath (see above)
• Jaundice: Skin and mucous membranes
• Angular stomatitis: Malnutrition, iron/B12 deficiency
• Glossitis: Nutritional deficiency
• Parotid enlargement: Alcoholism
• Loss of facial hair (in men), feminisation of features: Endocrine dysfunction
• Cushingoid facies: Iatrogenic (steroids for autoimmune hepatitis)

C. Gynecomastia (if examining upper body at this point)

• Bilateral tender breast tissue enlargement in men due to increased estrogen/decreased testosterone from liver failure and impaired hormone metabolism
• Also: Pubic and axillary hair loss, testicular atrophy (examine later)

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STEP 6: CHEST AND UPPER BODY

• Gynecomastia: As above
• Spider naevi: Distribution of SVC territory
• Chest hair loss / feminisation: Men with CLD
• Prominent chest veins: Collateral vessels if SVC obstruction, or inferior collaterals from portal hypertension
• Dupuytren's: Chest wall nodules (rare)
• Scratch marks: Pruritus (cholestatic liver disease - PBC, PSC, biliary obstruction)
• Respiratory examination: Reduced breath sounds at right base (hepatic hydrothorax - right-sided pleural effusion in cirrhosis due to diaphragmatic defects; represents 5-10% of all pleural effusions in cirrhosis)

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STEP 7: ABDOMINAL EXAMINATION

A. INSPECTION

1. Shape: Abdominal distension - generalised (ascites), flanks full/bulging ("full flanks"), central bulge (tense ascites), "frog abdomen"
2. Umbilicus: Everted/protruding (tense ascites); periumbilical hernia (hernia through weakened umbilical/epigastric region)
3. Caput medusae: Dilated tortuous veins radiating from the umbilicus in a "sun ray" pattern; represents recanalised paraumbilical vein draining to superficial epigastric veins; flow is away from umbilicus (centrifugal); pathognomonic of portal hypertension
4. Veins on abdomen: Distinguish caput medusae from inferior vena cava (IVC) obstruction:

   Feature	Caput Medusae (Portal HTN)	IVC Obstruction
   Distribution	Radiates from umbilicus	Flanks + lower abdomen
   Flow direction	Away from umbilicus (centrifugal)	Upward (cephalad) in lower abdomen

5. Striae: Stretch marks from rapid abdominal distension
6. Visible peristalsis: Not expected unless bowel obstruction
7. Respiratory movement: Reduced abdominal movement with respiration (tense ascites)
8. Scars: Paracentesis marks, prior surgery (diagnostic laparotomy, shunt surgery)

B. PALPATION

• Tenderness: Localised (SBP, hepatoma, cholangitis) vs. diffuse (SBP)
• Guarding/rigidity: Peritonitis (SBP)
• Note: In tense ascites, palpation may be difficult and misleading

• Start from right iliac fossa, move upward toward right costal margin
• Feel for liver edge on inspiration
• Normal liver: Not palpable (or just palpable at costal margin)
• Hepatomegaly in CLD:

  Character	Cause
  Firm, smooth, tender, enlarged	Acute hepatitis, congestive hepatopathy
  Firm, irregular/nodular, non-tender	Cirrhosis (shrunken/normal), hepatocellular carcinoma (HCC)
  Rock-hard, irregular, non-tender	HCC, metastatic disease
  Smooth, tender	Congestive cardiac failure, Budd-Chiari
  Pulsatile liver	Tricuspid regurgitation

• Note: In established cirrhosis, the liver may actually be small/shrunken (not palpable); the right lobe atrophies and the left lobe hypertrophies
• Measure span: Normally <12 cm in MCL; >12 cm = hepatomegaly

• Start from right iliac fossa, move diagonally toward left costal margin
• Enlarge spleen moves medially and downward; cannot get above it; dull to percussion; has a notch on its medial border
• Splenomegaly in CLD: Due to congestive splenomegaly (portal hypertension - blood backs up in splenic vein); causes hypersplenism (thrombocytopenia, leucopenia, anaemia)
• Grade splenomegaly:

  Grade	Measurement
  Grade 1 (mild)	Palpable below costal margin but less than 5 cm
  Grade 2 (moderate)	5-10 cm below costal margin
  Grade 3 (massive)	>10 cm below costal margin; may reach iliac fossa

• Distinguished from kidney: Can get above the spleen only if it is NOT enlarged; spleen moves with respiration; spleen is dull to percussion; spleen has a notch; kidney is ballotable

• Percuss from umbilicus toward the flank: Percuss until note becomes dull; mark the point
• Ask patient to roll to the opposite side (keep finger in place); wait 30 seconds
• Percuss again at the same point - if now resonant = shifting dullness (positive for ascites)
• Sensitivity ~83%, Specificity ~56% for ascites >1-1.5 L
• Best test for moderate ascites

• Patient/helper places edge of hand in the midline (to dampen fat wave)
• Examiner places one hand flat on one flank
• Examiner flicks/taps the other flank sharply
• A transmitted impulse felt on the resting hand = positive fluid thrill
• Indicates large ascites (grade 3); not reliable for small amounts
• Sensitivity ~58%, Specificity ~90%

• Patient kneels on all fours for several minutes (allows fluid to pool centrally)
• Percuss over the most dependent part (umbilicus area)
• Detects as little as 120 mL of fluid

• Simply the fullness/convexity of the flanks when the patient lies supine
• Sensitivity ~72%

• Bimanual palpation: Place one hand posterior (loin), one hand anterior
• In cirrhosis: Look for polycystic kidneys (associated with liver cysts - ADPKD)
• Large kidneys may be felt in renal amyloidosis or nephrotic syndrome (differential cause of ascites with SAAG <1.1)

• Umbilical hernia: Very common in tense ascites; examine for cough impulse
• Epigastric hernia
• Risk of rupture with tense ascites (umbilical hernia rupture = surgical emergency)

C. PERCUSSION

• Liver dullness: 2nd/3rd ICS to right costal margin (normal); assess span
• Splenic dullness: Left 9th to 11th ICS in mid-axillary line = Traube's space; dullness = splenomegaly
• Ascites: Shifting dullness (see above); flanks dull, centre resonant
• Fluid level: Can percuss upper limit of ascitic fluid

D. AUSCULTATION

• Bowel sounds: Normal / reduced (paralytic ileus in SBP/peritonitis) / absent (peritonitis)
• Hepatic bruit: Vascular bruit over liver = hepatocellular carcinoma (arterio-venous malformation within tumour), or acute alcoholic hepatitis (increased intrahepatic blood flow)
• Splenic rub: Splenic infarction (rare)
• Venous hum at umbilicus (Cruveilhier-Baumgarten syndrome): Continuous hum heard at umbilicus due to blood flowing through recanalised paraumbilical vein into caput medusae veins; augmented by Valsalva

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STEP 8: GENITALIA AND PERINEUM (Male)

• Testicular atrophy: Hallmark of chronic liver disease and hypogonadism; due to hyperestrogenism and suppressed LH/FSH
• Scrotal oedema: With severe ascites
• Loss of pubic/axillary hair: Feminisation

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STEP 9: LOWER LIMBS

• Bilateral pedal oedema: Pitting, bilateral, worse at end of day; due to hypoalbuminaemia + portal hypertension + secondary hyperaldosteronism
  • Pitting character: Press thumb firmly over pretibial area or dorsum of foot for 5-10 seconds; pit depth graded 1+ to 4+
  • Assess extent: Ankle, mid-calf, knee, thigh, sacrum (if bedridden)
• Muscle wasting: Quadriceps (best seen with knee extended), gastrocnemii - cirrhotic sarcopenia
• Peripheral neuropathy: Alcohol-related (loss of vibration, proprioception, ankle jerks)
• Scratch marks: Pruritus (cholestatic liver disease)
• Bruising: Coagulopathy

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STEP 10: NEUROLOGICAL EXAMINATION (for HE)

• Mental state / orientation: Time, place, person (West-Haven grading)
• Asterixis (flapping tremor): As described - characteristic of HE grades II-III
• Dysarthria/slurred speech: HE
• Rigidity, hyperreflexia: Severe HE (grades III-IV)
• Plantar responses: Extensor (Babinski positive) in severe HE
• Constructional apraxia: Simple tests - ask patient to draw a 5-pointed star, connect numbered dots (Number Connection Test) - impaired in minimal HE
• Altered consciousness/GCS: Grade IV HE

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STEP 11: COMPLETING THE EXAMINATION

1. Measure blood pressure in both arms
2. Examine for signs of the underlying aetiology (e.g., signs of alcohol use: parotid enlargement, Dupuytren's; signs of Wilson's: KF rings on slit lamp)
3. Examine the back: Sacral oedema (bedridden patients), spinal tenderness
4. Rectal examination: Haemorrhoids (portal hypertension), melaena, rectal varices
5. Fundoscopy: Hypertensive/diabetic retinopathy, Roth spots (endocarditis)
6. Urine dipstick: Haematuria (endocarditis, IgA nephropathy in liver disease), proteinuria (nephrotic syndrome)
7. DIAGNOSTIC PARACENTESIS: Ascitic fluid analysis - critical in new ascites or suspected SBP

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PART III: SUMMARY - KEY SIGNS AND THEIR MEANINGS

Signs of Chronic Liver Disease (Grouped by Region)

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Ascites: Grading and SAAG

• Grade 1: US-only detectable
• Grade 2: Moderate, detectable clinically
• Grade 3: Tense, marked distension

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Child-Pugh Score for Severity of Cirrhosis

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MELD Score

• Higher MELD = worse prognosis, higher transplant priority
• MELD ≥15: Consider transplant listing
• MELD >20: High short-term mortality, urgent referral
• MELD-Na (MELD + sodium) - improved accuracy

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Complications of CLD with Ascites (to look for and ask about)

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Sources

• Sleisenger & Fordtran's Gastrointestinal and Liver Disease - Chapter 93: Ascites and Its Complications (Pathogenesis, Diagnosis, Management, pp. 1799-1803); Chapter 94: Hepatic Encephalopathy (pp. 1815-1816); Chapter 92: Portal Hypertension
• Harrison's Principles of Internal Medicine, 22nd Edition (2025) - Chapter 347: Grading and Staging of Liver Disease, Child-Pugh Score, MELD Score (p. 819)
• Rosen's Emergency Medicine: Concepts and Clinical Practice - Chapter on Cirrhosis, Hepatic Encephalopathy, SBP (pp. 2494-2534)
• Bailey & Love's Short Practice of Surgery, 28th Edition - Chapter 69: Acute Liver Failure / Chronic Liver Disease clinical features (pp. 1659-1672)
• Goldman-Cecil Medicine, International Edition - Physical Examination for Cardiovascular/Abdominal Signs