5 Are there any rashes, arthralgias, arthritic joints, or conjunctivitis? (to question about autoimmune causes) Have there been any recent behavioral changes, especially in a teenager? (to evaluate for Wilson disease) Are bleeding, bruising, swelling, excessive sleeping, or mental status changes present? (to assess overall liver function) What medications are taken, and are any of them new? (to identify potential hepatotoxins) Is there a family history of liver diseases, early-onset emphysema, or iron overload? (to evaluate for genetic causes, such as Alagille syndrome, α1 antitrypsin disease, or hemochromatosis) 10 (For infants) Were there any infections during pregnancy? Were the newborn screens normal? It is also important to perform a meticulous physical examination, starting with the growth parameters of the child, including weight and height percentiles, as well as the growth curve Central and distal perfusion should be assessed While examining the abdomen, the liver size, contour, and texture should be noted, as well as an estimation of spleen size The presence or absence of abdominal tenderness and the location should be identified in children with reliable examinations The skin examination should include evaluation for bleeding, bruising, spider angiomas, caput medusa, excoriations or signs of pruritus, and palmar erythema The neurologic examination should include mental status evaluation, as well as observation for dysarthria, tremor, or rigidity Splenomegaly, stigmata of portal hypertension, and neurologic changes all point to more chronic causes of liver disease EVALUATION The most concerning etiologies for conjugated hyperbilirubinemia are the results of hepatocyte destruction or biliary obstruction Identification of these conditions should be the focus of the evaluation in the emergency department The emergency provider must quickly assess two things: (1) Does the child have impaired liver function, or just liver irritation/injury? and (2) Is the liver disease acute or chronic? Initial function tests should include: Albumin (reflects liver synthetic function, but also reflects nutritional status and is a negative acute phase reactant) Prothrombin time (PT) and international normalized ratio (INR) (reflects liver synthetic function, but also may be abnormal with vitamin K deficiency) Ammonia