Goodman & Snyder: Differential Diagnosis For Physical Therapists, 5th Edition

Goodman & Snyder: Differential Diagnosis for Physical Therapists,
5th Edition
Chapter 09: Screening for Hepatic and Biliary Disease
Answers to Practice Questions
1. (c) Technically, answer (b) is also correct because referred shoulder pain may be the only
presenting symptom of hepatic or biliary disease. However, when the overall referral
pattern is viewed, answer (b) leaves out the upper back and scapulae; answer (d) refers
to the part of the body between the neck and the abdomen and includes the primary pain
pattern present in the right upper quadrant but not the mid or upper back associated with
the referred pain pattern. Kehr’s sign—left shoulder pain associated with blood or air in
the abdominal cavity—is not part of the hepatic/biliary system.
2. Radiating pain to the mid back, scapula, and right shoulder occurs as the result of
splanchnic fibers (a network of nerves innervating the viscera of the abdomen) that
synapse with adjacent phrenic nerve fibers—the branch of the celiac plexus (also known
as the solar plexus) that innervates the diaphragm.
The liver is innervated by the hepatic plexus, also a part of the celiac plexus (see Fig. 3-
3). Interconnecting nerve fibers between the phrenic nerves and the brachial plexus then
refer pain to the right shoulder. These connections occur bilaterally, but most biliary
fibers reach the dorsal spinal cord through the right splanchnic nerve to produce pain
primarily in the right shoulder.
3. Normally, the breakdown of protein in the gut (whether derived from food or blood in
the stomach) produces ammonia that is transformed by the liver to urea, glutamine, and
asparagine. These substances are then excreted by the renal system. When the liver is
diseased and unable to detoxify ammonia, ammonia is transported to the brain, where it
reacts with glutamate, an excitatory neurotransmitter, thus producing glutamine.
Reduction in brain glutamate impairs neurotransmission, leading to altered nervous
system metabolism and function. Additionally, ammonia may cause the brain to produce
false neurotransmitters. The result of this ammonia abnormality is peripheral nerve
disease with numbness and tingling of the hands and/or feet that can be misinterpreted as
carpal/tarsal tunnel syndrome. Check also for asterixis.
4. Ask about numbness and tingling in the feet. Tarsal tunnel symptoms do not always
occur with upper extremity numbness and tingling, but when both are present, a medical
evaluation is required.
Ask the client about any associated signs and symptoms, especially constitutional
symptoms (see Systemic Signs and Symptoms Requiring Physician Referral at the end
of this chapter). Look for liver flap, liver palms, and other skin and nailbed changes.
Look for risk factors associated with liver impairment (e.g., alcohol use, hepatotoxic
medications, previous history of any type of cancer).
Copyright © 2013, 2007, 2000, 1995, 1990 by Saunders, an imprint of Elsevier Inc.
Answers to Practice Questions 9-2
If subjective and objective examinations do not reveal any red flags, treatment may be
initiated. If treatment does not result in objective or subjective improvement, ask the
client again about the development of any new symptoms, especially constitutional
symptoms or other associated symptoms discussed here.
Failure to progress in treatment should result in physician evaluation or reevaluation.
The development of any new systemic symptoms requires medical evaluation as well.
5. Jaundice is first noted as a yellowing of the sclerae of the eyes. The skin may take on a
yellow hue as well, but this is not as easily observed as the change in the eye. This
change in eye and skin color can also occur with pernicious anemia, a condition that
may be accompanied by peripheral neuropathy as well.
6. Given most people’s concern about their physical appearance, it is best not to point out
the change in eye color directly, but rather, ask some questions that may provide you
with the information needed. For example,
• Mrs. Jackson, have you ever been given a diagnosis of jaundice, hepatitis, or anemia?
• Are you experiencing any new symptoms or problems that we haven’t discussed?
• Have you noticed any smells or foods that you cannot tolerate?
• Have you (or your husband) noticed any changes in your skin or eyes?
• At this point, if nothing comes to light, you may broach your observation by saying,
“I have noted some yellowing of the white part of your eye. Is this something you
have noticed or discussed with your physician?”
7. (d)
8. (c) Answer (a) (decreased serum albumin) is not a good laboratory measure because
serum albumin has to be severely decreased for tissue damage to occur; coagulation
times is a much better indicator of potential tissue injury in a clinical setting.
9. (d)
10. (b)
11. (b) Albumin is a protein that is formed in the liver and that helps to maintain normal
distribution of water in the body.
Copyright © 2013, 2007, 2000, 1995, 1990 by Saunders, an imprint of Elsevier Inc.

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Goodman & Snyder: Differential Diagnosis for Physical Therapists,

Chapter 09: Screening for Hepatic and Biliary Disease

Answers to Practice Questions

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