Patient’s name : Mahadev Shinde.
Age : 48 years. Sex : Male
Occupation : Machine operator Address : Belagavi
Religion : Hindu
Ward : G + 3 free ward
CHIEF COMPLAINTS
1. Abdominal distension since 20 days
2. Swelling over lower limbs since 20 days
3. Pain around umbilical region since 20 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently alright 20 days ago, when he developed distension of
abdomen which was insidious in onset and progressive in nature. It first appeared
around the umbilicus and progressed to the whole abdomen.
Patient also complains of swelling in lower limbs which was insidious in onset
and progressive in nature.It progressed from ankles up to the knees in a span of
20 days. It was painless in nature and there is no diurnal variation. The swelling
aggravates on doing work at day time.
Patient also complains of pain over the umbilical region since 20 days which
was insidious in onset and progressive in nature, it was of dull type, non-radiating,
aggravated on doing work and relief on taking rest.
The pain was associated with moderate fever, which was insidious in onset with
no history of chills and rigor.
History of hematemesis- 15 days back, preceeding nausea present, vomitus
includes blood with food particles, non- projectile type.
History of bleeding per rectum - 2 episodes in 3 months, occured in
association with passing of stools.
No history of of diarrhoea , foul smelling stools , jaundice, reduced micturition or
loss of weight.
PAST HISTORY
The patient had 4 episodes of similar complaints in the past.
The 1st episode was in August 2019, for which he was admitted to KLE
Hospital,Yellur where tapping was done and 3.5 ltr fluid was removed.
The symptoms reappeared after a span of 2 months, which he showed in KLE
Hospital, Belagavi. He was given medication and found relief.
Then 3rd episode was in December 2019 and the final episode occurred in
January 2020.
The patient has undergone appendectomy earlier.
Not a known case of diabetes mellitus, hypertension , tuberculosis
No history of blood transfusion
FAMILY HISTORY - nothing significant
PERSONAL HISTORY
Diet - Mixed. Appetite - Normal. Sleep - Reduced.
Bladder - Reduced. Bowel - Reduced.
Habits - History of alcohol intake one quarter per day ( whiskey) since 9 years
1 quarter = 180 ml
(180*40) / 100 = 72 gm per day
History of tobacco chewing since 10 years, three packets per week
GENERAL PHYSICAL EXAMINATION
Patient is 48 years old male, who is moderately built and moderately nourished.
He is conscious, cooperative and well oriented to time, place and person.
VITALS - PR - 92 beats per minute. BP - 110/90 mm of Hg
RR - 16 cycles per minute. Temperature - Afebrile
Pallor - present. Icterus - absent. Cyanosis - absent. Clubbing - absent
Lymphadenopathy - absent. Edema - absent
HEAD TO TOE EXAMINATION
Scalp - grey hair , lustrous. Eyes - Pallor present, icterus absent; pupils normal
Nose - normal. Face - normal. Ears - normal
Mouth and oral cavity - normal.
Lower limb - bilateral pitting type oedema present till knee
Chest - gynaecomastia present
Abdomen - umbilicus horizontally stretched , uniformly distended , no prominent
veins seen
SYSTEMIC EXAMINATION
Abdomen - shape - uniformly distended , flanks full
Respiratory movement - abdominothoracic.
No visible peristalsis , umbilicus inverted , prominent veins absent , hernial
orifices absent
Operation scars for appendectomy present
No pigmentation , no branding marks
Signs of hepatocellular failure
Alopecia - present. Parotid swelling - absent. Gynecomastia - present
Spider navi - absent. Jaundice - absent. Palmar erythema - present
Clubbing - absent. Loss of shaving tendency - present
Loss of axillary , pubic , chest hair- present
Palpation -
Superficial - tenderness absent , no guarding , no rigidity
Deep - no organomegaly
Percussion -
Fluid thrill present ( Grade IV ascites)
Auscultation -
Normal bowel sounds heard
Respiratory system - Normal vesicular breath sounds heard
Cardiovascular system - Heart sounds S1 + S2 heard normally , no added
sounds heard
CNS - All sensory and motor functions of the patient are intact
DIAGNOSIS - Chronic liver disease with Grade IV ascites with signs of
portal hypertension and hepatocellular failure
