Chronic liver disease

• Clubbing
• Leukonychia
• Palmar erythema
• Dupuytren’s contracture
• Jaundice
• Spider naevi
• Gynaecomastia
• Loss of axillary hair
• Distended abdominal wall veins/‘caput medusae’ (portal hypertension)
• Hepatomegaly (but liver is often small in cirrhosis) 
• Splenomegaly (portal hypertension)
• Ascites

Signs of aetiology: Afro-Caribbean (sarcoid), slate-grey pigmentation/capillary glucose monitoring marks (haemochromatosis), track marks/tattoos (hepatitis C), xanthelasma (PBC), goitre/middle-aged female (autoimmune), emphysema (α1-antitrypsin deficiency)

Signs of decompensation: asterixis/confusion (encephalopathy), jaundice, ascites

Transplanted kidney

• Old AV fistula 
• Rutherford-Morrison scar (usually RIF)
• Smooth mass underlying scar (transplanted kidney)

Signs of aetiology: fingertip capillary glucose monitoring marks (diabetes), hearing aid (Alport syndrome), collapsed nasal bridge (granulomatosis with polyangiitis), butterfly rash (SLE), sternotomy (renovascular disease), flank masses (PKD)

Functionality: asterixis/confusion (uraemic encephalopathy), excoriations (uraemia), active marks in AV fistula, pale conjunctiva (anaemia), fluid retention 

Previous renal replacement therapy: AV fistula, central line and peritoneal dialysis scars

Complications of immunosuppression: tremor (calcineurin inhibitor), cushingoid/bruising (steroids), skin lesions/excisions (immunosuppression)

Hepatosplenomegaly

• Hepatomegaly/splenomegaly/both

Signs of hepatomegaly aetiology: signs of chronic liver disease, lymphadenopathy (malignancy/lymphoma), peripheral oedema/raised JVP (right ventricular failure)

Signs of splenomegaly aetiology: hand deformity (RA/Felty’s syndrome), signs of chronic liver disease, pale conjunctiva (leukaemia/ myeloproliferative/haemolytic anaemia), lymphadenopathy (lymphoma)

Polycystic kidneys

• AV fistula (if undergone dialysis)
• Hypertension
• Pale conjunctiva (anaemia)
• Flank scar (if either kidney has been removed)
• Bilateral ballotable flank masses
• Hepatomegaly (hepatic cysts)

Liver transplant

• Signs of chronic liver disease (but most resolve)
• Mercedes Benz modification scar      

Signs of aetiology: Afro-Caribbean (sarcoid), slate-grey pigmentation/capillary glucose monitoring marks (haemochromatosis), track marks/tattoos (hepatitis C), xanthelasma (PBC), goitre/middle-aged female (autoimmune), emphysema (α1-antitrypsin deficiency) 

Complications of immunosuppression: tremor (calcineurin inhibitor), cushingoid/bruising (steroids), skin lesions/excisions (immunosuppression)

Combined kidney-pancreas transplant

• LIF scar (renal graft)
• RIF scar (pancreas graft)
• Smooth mass underlying LIF scar (transplanted kidney)

Signs of diabetic complications: visual aids (retinopathy), Charcot joints, toe ulcers/amputations, neuropathy

Renal graft functionality: asterixis/confusion (uraemic encephalopathy), excoriations (uraemia), active marks in AV fistula, pale conjunctiva (anaemia), fluid retention

Pancreas graft functionality: fingertip capillary glucose monitoring marks, insulin injection marks

Previous renal replacement therapy: AV fistula, central line and peritoneal dialysis scars (but transplant may have been done pre-emptively)

Complications of immunosuppression: tremor (calcineurin inhibitor), cushingoid/bruising (steroids), skin lesions/excisions (immunosuppression)

Polycythemia rubra vera

• Dusky cyanosis
• Hypertension
• Facial plethora
• Splenomegaly

Hereditary spherocytosis

• Pale conjunctiva
• Mild jaundice
• Splenomegaly

Primary biliary cholangitis

• Middle-aged female
• Jaundice
• Skin hyperpigmentation
• Excoriations
• Xanthelasma
• Hepatomegaly

Signs of complications: signs of chronic liver disease 

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1. Chronic liver disease
2. Renal transplant
3. Hepatosplenomegaly
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