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Name/age/sex/occupation/address

Presenting complaints

H/o presenting complaints

Abdominal pain:

o Duration

o Site

o Nature(continuous/intermittent)

o Character(constant/colicky)

o Severity

o Radiation

o Aggravating / relieving factors

o Associated features(fever/nausea/ vomiting/ defecation)

Abdominal distension:o Duration

o Onset(insidious/acute)

o Site(localised/uniform)

o Progress

o RVF features

Leg swelling

Breathlessness

Chest pain

o Liver features:

Loss of appetite

Hematemesis/ Malena

Constipation/ Obstipation

o Renal:

Oliguria

Puffiness of face

Frothy urine(Nephrotic syndrome)

o Vomiting/ Blood in vomit

No of episodes

Duration

Projectile

Associated with nausea/ headache/ blurring of vision

Quantity

Character(colour/smell/blood streaks)

Associated with food intake

Associated features(pain/malena/hematemesis/ loss of consciousness)

H/o drug intake(NSAIDS, Steroids)

o Jaundice

Duration

Itching Colour of urine/ Stools

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Any fever with rigor

Treatment taken

o Stools:

Frequency

Colour(dark/ tarry black/ pale)

Consistency(Solid/ liquid)

Nature(Sticky/mucoid)

Associated pain

Blood streaks

o Mass in abdomen

Site

Duration

Progression

Associated pain

Negative History:o Fever

Duration/ Time of occurrence

Grade (high/low)

Nature(continuous / remittent)

Associated with rigors/ sweating

o Upper GIT:

Dysphagia(solids/liquids/both)

Heart burn

Vomiting

o

Urinary Tract

Dysuria

Pain/Burning micturition

Oliguria

Hematuria

Frequency

Fever with rigor

o H/o bleeding diathesis

Epistaxis

Bleeding gums

Menorrhagia

Prolonged bleeding after trauma

H/o loss of appetite/ weight loss - TB & malignancy

H/o swelling of legs

H/o puffiness of face - renal

H/o pruritides, bleeding per rectum

H/o altered sleep pattern

Past History:

H/o previous similar episode

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H/o surgery, drug intake

Jaundice

o H/o tattooing

o H/o drug intake

o H/o blood transfusion

o H/o exposure to STDs

o H/o vaccination

Ascites

o Previous abdomen surgeries(Scar - irritation)

o H/o TB, DM, IHD, HT

o H/o renal colic

Family History:

Any similar history(cirrhosis/wilsons disease/AT / Hep A/B/E)

Personal history:

Smoking

Alcohol

Diet(appetite)

Sexual history

Menstrual history, Obstetric history

Treatment history:

Summary:

Age/sex/name? Personal H/o? Family H/o? presenting complaints? Other relevant positive

features

Examination of Abdomen

General examination:

Conscious

Co-operative

Built

Afebrile

Cyanosis

Anemia

Jaundice

Clubbing(cirrhosis/ IBD/ Malabsorption syndrome)

Significant lymphadenopathy

Pedal oedema

Markers of liver cell failure

o

Head:

Alopecia

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o Eye:

Bitot spots(Vit A)

Sub conjunctival haemorrhage(Vit K)

Colour(Anemia - pale/ jaundice - yellow)

Metabolism(KF ring/ wilsons/ xanthelasma - fat)

o

Face:

Medial supraciliary madarosis

Sunken eyes, cheeks

Loss of facial hair

Parotid enlargement

o Mouth

Bleeding gums

Fetor hepaticus

o Chest

Spider naevi Gynaecomastia

Atrophy of breast

Loss of pectoral hair, axillary hair

Pectoral muscle atrophy

Dilated veins

o Hands:

Anemia

Bounding pulse

Clubbing

Duputryens contracture

Flapping tremor/ asterexis

Erythema palmar

Leuconychia

o Abdomen:

Distension

Dilated veins(caput medusa)

o Testis:

Atrophy

Pubic hairloss

Tumour

o Lower limbs:

Pedal oedema

Chronic leg ulcers

o General:

Pruritis/spiderman appearance

Markers of TB

Markers of HIV

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Vital signs:

Pulse - Rate/Rhythm/Volume/Character/RF delay/felt in all peripheral vessels/ condition of vessel

wall

BP - .mm Hg, ..limb, posture

Respiratory rate - Rate/Rhythm / Type

Temperature

JVP

Systemic examination of Abdomen:

Inspection:

Shape:o Scaphoid/ flat/ distended - uniform or localised

o Flanks (free / full)

Umbilicus

o Position

o Shape(slit/inverted/ everted)

o Nodules - Sister Mary Josephs nodules

Movement of abdomen wall

o Movement with respiration

o Visible pulsations

o Visible peristalsis

Skin and surface of abdomen

o Supine position

Stretched, shiny, scars, surgeries, sinuses, strine(Cushings - purple strine)

o Head rising

o Divarication of recti

o Standing position

o Dilated veins

o External Genitalia

o

Cough impulseo Genitalia normal

Palpation:

1. Superficial palpation

o Warmth

o Tenderness

o Thrills

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2. Deep palpation

o Liver:

A tender/non tender swelling is palpablecm below/above right costal margin in

MCL. Extending from (medial) to (lateral), with ...(smooth/nodular) surface and (sharp/rounded) margins, ..(soft/firm/hard) in

consistency. It (moves/not) with respiration, not bimanually palpable, not able to

insinuate fingers under the costal margin.

o Spleen:

o Site

o Surface

o Tender - spleenic abscess or IMV

o Extent

o

Notch on the medial bordero Consistency

It moves with respiration, not bimanually palpable, not ballotable, upper

border, cannot be felt, colonic band of resonance not felt

o Kidney:

o Normally lower rt. Pole in thin individuals

o It moves with respiration, bimanually palpable, ballotable, colonic band of

resonance felt

o Others:

o Direction of blood flow

o

Fluid thrill

o Abdominal girth movement

o Inguinal/Para Aortic/supraclavicular nodes

Percussion:

Fluid

o Shifting dullness

o Puddle sign

Liver

o

Dullness and span Spleen

o Dullness

o Traubes space

Kidney

o Colonic band of resonance

Auscultation:

Bowel sounds:

o 10 to 15/min small bowel

o 3 to 5/min large bowel

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Bruit:

o Renal(Mid abdomen, around midline)

o Liver(haemangioma, HCC, Acute alcoholic hepatitis)

o Aortic bruit

Venous hum:

o

Midway between umbilicus and rt. Costal margin

PDV

Collaterals in Portal HT

Cruvilhier - Baumgartner syndrome

Rub:

o Perispleenitis

o Perihepatitis

Succussion splash:

Other systems:

CVS:

o S1, S2 heard (to rule out RVF)

RS:

o NVBS, Basal crepitation(PE, TB)

CNS:

o Normal (Hepatic encephalopathy, Peripheral neuropathy)

Diagnosis:

Chronic decompensated liver disease with portal hypertension and ascites