The patient was an obese, elderly man who was of average height. He looked deeply jaundiced.
On examination of his head he had marked parotid enlargement. Apart from this there were no other abnormalities.
His hands did not show any abnormalities on examination. There were erythematous plaques with silvery scales on his elbows.
There was no abnormality detected in his neck.
The chest did not show any spider naevi, hair growth looked normal and there was no gynaecomastia.
On examination of the abdominal wall there appeared to be fullness in the upper abdomen. There were large erythematous plaques with silvery scales in the lower abdomen. On palpation a mass was palpable in the right hypochondrium. The edge was well defined. The surface appeared nodular and the consistency of the lump was hard. It was non-tender. It was not possible to get between the lump and the costal margin. The percussion note over the lump was dull and this dullness was continuous with the liver dullness, which had its upper border at the fifth right intercostal space in the mid-clavicular line. There was a systolic bruit over one of the nodules in the mass.
No other lumps were palpable there was no free fluid in the abdomen.
♥ Deep jaundice would suggest a hepatocellular cause for jaundice. Obstructive jaundice is unlikely to be given as a case in a clinical examination and haemolytic jaundice is unlikely to be so severe without the patient being grossly anaemic and severely ill.
ª Parotid enlargement would suggest alcohol abuse as a cause or a contributory factor in the pathogenesis.
¨ Psoriasis (erythematous plaques with silver scales) may be associated with cirrhosis of the liver if the patient was treated methotrexate. At this point the diagnosis points to cirrhosis of the liver with alcohol or cirrhosis as a cause. As the patient has deep jaundice it is likely to be a complication of cirrhosis with decompensation.
§ The patient does not have any signs of hepatocellular dysfunction hence it is difficult to substantiate a clinical diagnosis of cirrhosis. (No white nails, no palmar erythema, no spider naevi, normal growth of body hair, no gynaecomastia)
♥ There are no signs of portal hypertension (no petechiae, no flap, no ascites, no enlargement of the spleen). Again this makes it difficult to substantiate a clinical diagnosis of cirrhosis of the liver. (Subclinical disease cannot be excluded)
ª A hard nodular liver suggests cirrhosis of the liver, hepatoma or metastases. We have not found any clinical features of cirrhosis so this leaves the latter two.
¨ A bruit in the liver suggests hepatoma, metastases or alcoholic hepatitis. There are no signs of hepatocellular failure (apart fom jaundice) hence alcoholic hepatitis is excluded.
§ This leaves the diagnosis as hepatoma or metastases. As there is evidence for contributory factors for chronic liver disease (parotid enlargement –alcohol, psoriasis-iatrogneic liver damage), the likely diagnosis is hepatoma of the liver.
