Patient name : Mahadev Shinde.
Age : 48 years. Sex : Male
Occupation : Machine operator Address : Belagavi
Religion : Hindu Bed no. : A-16.
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 , when he developed distension of
abdomen which was insidious in onset and progressive in nature. It first appeared
around the umbilicus and progress to the whole abdomen.
Patient also complains of swelling over lower limbs which was insidious in onset
and progressive in nature. The swelling progressed from ankles up to the knee in
the span of 20 days. It was painless in nature and there is no diurnal variation.
Does swelling aggravates on doing work at day time.
patient also complains of pain over the umbilical region which was insidious in
onset and progressive in nature it was dull type of pain non radiating aggravated
on doing work and relief on taking rest p
The pain was associated with moderate fever. Which was insidious in onset with
no history e of chills and rigor.
Patient also complains of breathlessness on doing routine work
History of vomitting with blood 15 days back
History of bleeding through rectum - 2 episodes in 3 months
No history of of melena , diarrhoea , foul smelling stools , reduced micturition , loss
of weight
PAST HISTORY
History of similar complaints in past he had 4 episodes of similar complaints in
the past
1st episode- August 2019 - 6 months back for which he was admitted in KLE
Hospital Yellur where tapping was done and three and half litres of fluid was
removed then after a span of 2 months the symptoms again appeared. Which he
showed in KLE Hospital Belagavi where he was given medication and was
relieved. Then 3rd episode came in the month of December and final episode in
month of January
Patient has undergone appendectomy surgery
Not a known case of diabetes mellitus, hypertension , tuberculosis
No history of blood transfusion
No history of jaundice
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 - present. Cyanosis - absent. Clubbing - absent
Lymphadenopathy - absent. Edema - absent
HEAD TO TOE EXAMINATION
Scalp - grey hair , lustrous. Eyes - Pallor and icterus present , pupil 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 appendicitis
No pigmentation , no branding marks
Signs of hepatocellular failure
Alopecia - present. Parotid swelling - absent. Gynecomastia - present
Spider navi - absent. Jaundice - present. Palmar erythema - present
Signs of hepatocellular failure.
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 with signs of hepatocellular failure
