Upper Border of the Liver

We saw an interesting physical sign during the teaching sessions.
The patient was an elderly man who was tall but very thin. His face was gaunt with sunken malar regions.
On examination of his hands we noticed that his fingers were clubbed, there was tar staining of his fingernails and he had bilateral Dupuytren’s contractures.
There were no physical signs of note when examining his neck. His chest appeared hyperinflated.
His abdomen was scaphoid in shape but the upper part was locally distended and this enabled us to note the lower edge of his liver about 3 fingerbreadths below the costal margin. This was confirmed by palpation.
The other point raised by the student who examined the patient was that the subcostal angle was splayed out and on the basis of this and the fact that his chest appeared hyperinflated he suggested that the patient had chronic obstructive pulmonary disease.
On percussion of the liver we noticed that the upper border was not at the 5th intercostal space in the mid-clavicular line but was much lower. Indeed, the percussion note was resonant right down to the costal margin.
The liver was not enlarged it was pushed down by the hyperinflated lungs!
This is an important learning point. Never say the liver is enlarged until you have percussed the upper border and made sure the liver is not displaced downwards.
The patient was thin due to alcoholism and self-neglect. He also had bronchiectasis and this was the cause of clubbing.