Skin Changes in Liver Impairment

Liver Impairment and Skin Changes

• Liver impairment from cancer or liver disease can cause skin changes such as angioma and spider angioma (spider nevus), a permanently dilated group of superficial capillaries or venules.

Palpable Mass

• A painless sternal or chest wall mass may be palpated when evaluating the head and neck region.
• The primary tumor is usually a lymphoma, multiple myeloma, or carcinoma of the breast, kidney, or thyroid.
• Involvement of the chest wall and nerve roots can result in pain, with radiation of pain to the affected nerve roots.

Case Study

• A 53-year-old university professor presented with severe left shoulder pain radiating across her chest and down her arm, rated as a 10 on the NRS.
• Past medical history included ovarian cancer 10 years prior, and recent stressors.

Clinical Presentation

• Vital signs: BP 220/125 mm Hg, pulse 88 beats/minute, pulse oximeter 98%, and oral temperature 98.0°F.
• The therapist reproduced the symptoms with moderate palpation of the eighth rib and side bending motion to the left side.

Screening for Breast Conditions

• Breast cancer, heart disease, recent upper respiratory infection (URI), trauma, and surgeries (e.g., mastectomy, breast reconstruction) should be considered in the past medical history.
• Clinical signs and symptoms include:
  • Palpable breast nodules or lumps
  • Breast pain with possible radiation to the inner aspect of the arm
  • Skin surface over a tumor may be red, warm, edematous, firm, and painful
  • Skin dimpling
  • Unusual nipple discharge or bleeding
  • Pain aggravated by jarring or movement of the breasts

Causes of Breast Pain

• Mastodynia: irritation of the upper dorsal intercostal nerve causes chest pain associated with ovulatory cycles
• Mastitis: inflammatory condition associated with lactation and clogged duct, resulting in a red, swollen, and painful breast
• Benign tumors and cysts: fibrocystic breast disease, intraductal papilloma, fat necrosis, and mammary duct ectasia

Paget's Disease

• A rare form of ductal carcinoma affecting the nipple, characterized by a red (scaly) rash, itching, or bleeding on the breast that often surrounds the nipple and areola
• Symptoms are unilateral, and the breast may be sore, itch, or burn

Associated Signs and Symptoms

• Non-cardiac causes of chest or breast pain vary according to the system involved (e.g., pleuropulmonary, GI)
• Constitutional symptoms and changes in vital signs may be present if an underlying infectious or inflammatory process is causing pain or symptoms

Red Flags and Signs

• A patient with left shoulder pain and a history of trauma, sudden onset of symptoms, and constant pain should be referred to a medical doctor immediately.
• Kehr's sign is a indicator of spleen rupture, characterized by ipsilateral left shoulder pain and tenderness below the costal margin in the upper left quadrant.

Medical Conditions

• Ruptured spleen: a medical emergency requiring immediate attention, characterized by sudden onset of symptoms, severe pain, and possible collapse.
• Achalasia: a condition characterized by the inability of the lower esophageal sphincter (LES) to relax during normal peristaltic movement, leading to megaesophagus or bird beak on radiological examination.
• Gastroesophageal Reflux Disease (GERD): a condition characterized by the backward movement of stomach acids and other contents, damaging the food pipe and causing heartburn, regurgitation, and belching.
• Peptic Ulcer: a loss of tissue lining in the lower esophagus, stomach, or duodenum, caused by factors such as GERD, infection, or NSAIDs, and characterized by epigastric pain, night pain, and radiating back pain.
• Diverticular Disease: a condition characterized by the ballooning of the mucosa through weakened areas in the colon wall, leading to diverticulosis, and possible inflammation and infection (diverticulitis).
• Appendicitis: an inflammation of the vermiform appendix requiring surgery, characterized by severe abdominal pain, nausea, and possible rupture leading to peritonitis.
• Gastrointestinal (GI) Bleeding: a condition characterized by bleeding in the GI tract, appearing as mid thoracic back pain with radiation to the right upper quadrant, and diagnosed through serial hemoccult and lab tests.
• Constipation: a condition characterized by prolonged retention of fecal content in the GI tract, resulting from decreased motility of the colon or difficulty in expelling stool, and often causing back pain.

Special Considerations

• Murphy's Sign: a diagnostic sign for cholecystitis, characterized by pain in the inferior margin of the rib cage on the right side during inspiration.
• McBurney's Point: a diagnostic sign for appendicitis, characterized by point tenderness on an imaginary line between the umbilicus and the anterior superior iliac spine (ASIS).
• Obturator or Psoas Abscess: a condition characterized by lower abdominal pain, often caused by diverticulitis, Crohn's disease, pelvic inflammatory disease, or appendicitis.

Clinical Signs and Symptoms

• GI diseases: often characterized by symptoms such as fever, night sweats, abdominal pain, loss of appetite, and back, pelvic, abdominal, hip, or knee pain.
• NSAIDs: may cause gastrointestinal complications, including stomach upset, pain, and ulceration, as well as skin reactions, tinnitus, CNS changes, and renal involvement.
• GI Bleeding: characterized by symptoms such as coffee ground emesis, bloody diarrhea, bright red blood, melena, or reddish or mahogany-colored stools.
• Constipation: characterized by symptoms such as back pain, pressure on sacral nerves, and aching discomfort in the sacrum, buttocks, or thighs.