Leukonychia, or “white nail” is sometimes found in liver disease. In particular, it may be an indication of hypoalbuminemia. With a high pre-test probability of late-stage disease (ie. thrombocytopenia, hyponatremia) synthetic dysfunction may be reflected in the nail exam.
Remember to begin your physical exam with a careful inspection of the hands! Not only can you find leukonychia, but you may detect signs like palmar erythema, Dupuytren’s contracture, poor hygiene and a rapid radial pulse (subtherapeutic beta blockade).
In the image above, note the pallor of the nail; it extends almost to the top.