General appearance

• Jaundice - yellow discoloration of sclerae and skin from hyperbilirubinemia.
• Muscle wasting - particularly of the temporalis muscles, thenar and hypothenar eminences, and proximal limbs.
• Easy bruising, purpura, or petechiae - due to impaired synthesis of coagulation factors and/or thrombocytopenia.
• Scratch marks (excoriations) - may reflect pruritus in cholestatic disease.
• Peripheral edema - due to hypoalbuminemia, sodium retention, and portal hypertension.

Hands and arms

• Palmar erythema - non-tender symmetrical redness, most prominent over the thenar and hypothenar eminences and fingertips.
• Spider angiomas (spider naevi) - central pulsatile arteriole with radiating fine vessels; they blanch on pressure and refill from the centre. Usually occur on the face, neck, upper chest, and arms.
• Leukonychia / Terry nails - diffuse whitening of the nail bed, sometimes with a distal reddish-brown band.
• Clubbing - may occur, especially with cholestatic liver disease.
• Dupuytren contracture - fixed flexion deformity, often associated with alcohol use disorder.
• Asterixis (flapping tremor) - indicates metabolic encephalopathy, often hepatic encephalopathy, rather than chronic liver disease itself.

Face and mouth

• Parotid enlargement - classically associated with alcohol-related liver disease.
• Fetor hepaticus - sweet, musty breath odor in advanced hepatic failure.
• Xanthelasma or xanthomas - suggest chronic cholestasis, such as primary biliary cholangitis.

Endocrine and sexual features

• Gynecomastia - breast enlargement in men from altered estrogen-androgen balance.
• Loss of axillary and pubic hair, reduced body hair, and testicular atrophy in men.
• In women, menstrual irregularity or amenorrhea may occur.