USMLE® Step 2 CK Question of the Day: Jaundiced skin

Today, we’re examining a clinical case of a 38-year-old man brought to the emergency room by EMS showing signs of intoxication. Which exam finding is most likely present and should be further assessed to determine the cause of this patient’s condition?

A 38-year-old man is brought to the emergency department by EMS after being found on the side of the road intoxicated from alcohol. The patient presents frequently to the emergency department with similar presentations. The patient is awake and reports an episode of blood in his vomitus that morning and an increase in abdominal girth for the past few days. Past medical history is significant for alcohol use disorder. Temperature is 37.0°C (98.6°F), pulse is 108/min, respirations are 18/min, blood pressure is 110/60 mmHg, and oxygen saturation is 97% on room air. Physical examination shows jaundiced skin and icteric sclerae.

Which of the following physical examination findings is most likely to be present and should be assessed further to determine the underlying cause of this patient’s presentation?

A. Flank dullness to percussion

B. Blood per rectum on digital rectal exam

C. Absent bowel sounds on auscultation

D. Auspitz sign

E. Jugular venous distention

Scroll down for the correct answer!

The correct answer to today’s USMLE® Step 2 Question is…

A. Flank dullness to percussion

Correct: See Main Explanation.

Incorrect Answer Explanations

B. Blood per rectum on digital rectal exam

Incorrect: Blood per rectum on digital rectal exam is more often seen in lower gastrointestinal bleeds such as with hemorrhoids or diverticulosis or with brisk upper gastrointestinal bleeding. This patient’s presentation is suggestive of cirrhosis with hematemesis and abdominal distention suggesting ascites. The abdominal distension should be further assessed with physical examination and imaging.

C. Absent bowel sounds on auscultation

Incorrect: Absent bowel sounds on auscultation is suggestive of bowel obstruction or ileus. Although it can be present in patients with abdominal distention, this patient’s presentation is more suggestive of ascites, which will manifest as flank dullness to percussion.

D. Auspitz sign

Incorrect: The Auspitz sign refers to the visualization of pinpoint bleeding after removal of scale overlying a psoriatic plaque. This patient’s presentation does not correlate with psoriasis.

E.Jugular venous distention

Incorrect: Jugular venous distention is usually seen in patients with right heart failure, tension pneumothorax, or cardiac tamponade among others disease states. This patient’s presentation is suggestive of cirrhosis, which does not usually cause jugular venous distention.

Main Explanation

The patient in this vignette has concerning features for gastroesophageal varices secondary to portal hypertension from cirrhosis, including history of alcohol use disorder, hematemesis, increased abdominal girth, and jaundice of the skin.  

Patients with gastroesophageal varices caused by cirrhotic portal hypertension typically report symptoms like jaundice, fatigue, and abdominal swelling; as well as symptoms of altered mental status, such as confusion or disorientation. They might also have a history of cirrhosis, alcohol use disorder, or viral hepatitis. Increased abdominal girth is usually due to accumulation of fluid in the peritoneal cavity, known as ascites. Flank dullness to percussion is highly suggestive of ascites, which would suggest underlying cirrhosis and should be worked up with coagulation studies, liver function tests, and abdominal imaging. Other physical examination findings in cirrhosis include caput medusae, palmar erythema, asterixis, hepatomegaly, and splenomegaly. 

Major Takeaway

Patients with gastroesophageal varices secondary to portal hypertension from cirrhosis can present with hematemesis, jaundice, and increased abdominal girth. Physical examination findings in patients with cirrhosis may include flank dullness to percussion (indicating ascites), caput medusae, palmar erythema, asterixis, hepatomegaly, and splenomegaly.

Want to learn more about this topic?

Watch the Osmosis video: Gastroesophageal varices: Clinical sciences

References

• Chavez‐Tapia, N. C., Barrientos‐Gutierrez, T., Tellez‐Avila, F., Soares‐Weiser, K., Mendez‐Sanchez, N., Gluud, C., & Uribe, M. (2011). Meta‐analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding–an updated Cochrane review. Alimentary pharmacology & therapeutics, 34(5), 509-518.
• Simonetto, D. A., Liu, M., & Kamath, P. S. (2019, April). Portal hypertension and related complications: diagnosis and management. In Mayo Clinic Proceedings (Vol. 94, No. 4, pp. 714-726). Elsevier.
• Lesmana, C. R. A., Raharjo, M., & Gani, R. A. (2020). Managing liver cirrhotic complications: Overview of esophageal and gastric varices. Clinical and molecular hepatology, 26(4), 444.
• Cattau, E. L., Benjamin, S. B., Knuff, T. E., & Castell, D. O. (1982). The accuracy of the physical examination in the diagnosis of suspected ascites. Jama, 247(8), 1164-1166.

Want more USMLE® Step 2 CK practice questions? Try Osmosis from Elsevier today! Access your free trial and discover why millions of current and future clinicians and caregivers love learning with us.