HISTORY. Determine if the patient has experienced personality changes such as agitation, for-getfulness, and disorientation. Inquire about fatigue, drowsiness, mild tremors, or flulike symptoms. Ask about any past or present symptoms that may indicate cirrhosis, such as changes in bowel habits or menstrual irregularities. Elicit a history of easy bruising, nosebleeds, or bleeding gums. Determine the patient's drinking patterns and how long they have existed. Determine if the patient has had early-morning nausea and vomiting, anorexia, indigestion, weight loss, weakness, lethargy, epigastric discomfort, or altered bowel habits. Ask about any recent sexual dysfunction.
PHYSICAL EXAMINATION. Inspect for signs of muscle atrophy. Note whether the patient's abdomen is protruding. Assess the patient's skin, sclera, and mucous membranes, observing for poor skin turgor, signs of jaundice, bruising, spider angiomas, and palmar erythema (reddened palms). Observe the patient's trunk, and note the presence of gynecomastia (enlarged breasts). Observe the abdomen for distension, an everted umbilicus, and caput medusae (a plexus of dilated veins about the umbilicus); measure the abdominal girth.
When assessing the patient's upper extremities, test for asterixis (liver flap or flapping tremor). Have the patient stretch out her or his arm and hyperextend the wrist with the fingers separated, relaxed, and extended. The patient in stages II (impending) and III (stuperous) of hepatic encephalopathy may have a rapid, irregular flexion and extension (flapping) of the wrist. Note any tenderness or discomfort in the patient's abdomen. Palpate for hepatomegaly by gently rolling the fingers under the right costal margin. The liver is normally soft and usually can be felt under the costal margin. Percuss the patient's abdomen. Note a shifting dullness in the abdomen if ascites is present. Auscultate the abdomen and assess for hypoactive, hyperactive, or normal bowel sounds.
PSYCHOSOCIAL. Cirrhosis is a chronic disease that dictates lifestyle changes for the patient and significant others. Determine the patient's response to the diagnosis and his or her ability to cope with change. Identify the patient's past ability to cope with stressors, and determine if these mechanisms were successful.
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