[ACCM]

History

Particulars

Name: B. Baral
Age: 56 yrs. Sex: Male
Religion: Hindu
Education: M.A
Occupation: Retired Government Officer
Marital Status: Married
Address: Gahana Pokhari
Date of admission: 29th Oct 06’.
Mode of admission: OPD
Date of examination: 30th Oct 06’

Chief Complaints
• Swelling of abdomen - 1 month
• Pain in abdomen - 1 month
• Fever - 1 month
• Swelling of both legs - 1 week

History of Present Illness
According to the patient, he was apparently well one month back. Then he had generalized swelling of abdomen which was gradual in onset, progressive and associated with diffuse pain over the whole abdomen. Pain was insidious in onset, burning type, shifting in different regions of abdomen but not radiating, constant and moderately severe. No aggravating and precipitating factors were known but pain was relieved by defecation.
These symptoms were also accompanied by fever which was insidious in onset, continuous with maximum recorded temperature of 103° F and associated with chills but no rigors or sweating.
Since last week he had had bilateral swelling of legs which started from thigh and moved towards the leg with no diurnal and postural variation. There is no history of stiffness and pain.
He has no history of headache, burning micturition, vomiting, hematemesis, malena, breathlessness and chest pain.

Past History
• Hypertensive for last 15 yrs, on medication for last 10 years
• Known case of Diabetes Mellitus II for last 5yrs, on medication for last 2 yrs.
• No history of asthma, Tuberculosis
• No history of blood transfusion.
• No history of past surgeries.

Personal History
• Bowel habits: Normal
• Appetite: Decreased
• Sleep: Unaltered
• Urinary habits: Normal
• Smoking habits: Non-smoker
• Alcohol consumption: Chronic alcoholic with 40 units/week for last three years

Family History
• Mother is hypertensive.
• Brother is diabetic and had Tuberculosis 10 years back and was treated successfully.
• Father is asthmatic.
• There is no history of heart disease, stroke or any infection in the family.

Socioeconomic History
He is a retired government officer, from a middle class joint family with four members, and he has a properly maintained sanitary house with good provision of safe drinking water and toilet facilities.

Drug and Allergy History
• Drugs for hypertension for last 10 years.
• Drugs for Diabetes Mellitus II for last 2 years
o Metformin
o Glimperide
o Ranitidine (Aciloc)
• No known history of allergy to drug, dust, food and sunlight.

Clinical Examination

A. General Examination

1. General Characteristics
• Appearance: Well looking, conscious
• Co-operation: Cooperative
• Oriented to Time, Person and Place
• Body built: Well built
• Nutritional status: Good
• Decubitus: Propped up
• Fetor Hepaticus present
• Intravenous Cannula in situ at right hand.

Pallor – Not present
Icterus – Mild
Lymphadenopathy – Not present
Leuconychia – Not present
Clubbing – Present, Fluctuation test positive
Cyanosis – Not present
Oedema – Mild edema present on the lower limb
Dehydration – Not present

2. Vitals
Pulse: Pulse is 74/min. in the right radial artery in semi supine position, regular in rhythm, fair in volume, normal in character, bilaterally symmetrical, the arterial wall is just palpable, there is no radio-radial and radio-femoral delay. All the peripheral pulses are palpable
Blood Pressure: 120/80 mm of Hg in the right upper arm in sitting position. There is no postural drop.
Respiration: 18 breaths/min in sitting position, normal in depth and is abdomino-thoracic type.
Temperature: 98ºF in right axilla.
JVP: not raised

B. Systemic Examination

Abdominal Examination

Inspection
Generalized distension of abdomen.
• Movement is not symmetrical with respiration.
• Umbilicus centrally placed and everted.
• Smooth and shiny skin
• Visible superficial veins
• Loss of hairs around the pubic region
• Flanks full
• No scar marks, distended vessels, pulsations, pigmentation

Palpation

Superficial Palpation
• Temperature was not elevated, abdomen was firm on palpation. No superficial mass, lymph node and tenderness were felt.

Deep Palpation
• Liver, spleen and kidney were not palpable because of firm, distended abdomen.

Percussion
• Fluid thrills present
• Shifting dullness present

Auscultation
• Normal bowel sounds heard, one every 3 minute
Respiratory System: Bilateral gynaecomastia is present, bilateral vesicular sound heard, no added sound.
Cardiovascular System: First and second heart sound heard no murmur.
Central Nervous System: Intact

Provisional Diagnosis
Liver cirrhosis with known case of Hypertension and Diabetes Mellitus.

Differential Diagnosis
• Congestive Heart Failure
• Myxoedema
• Nephrotic Syndrome
• Hepatocellular Carcinoma
• Intestinal Tuberculosis

Investigation
• Blood: Hb%, TC, DC, ESR, PT, Random sugar, Albumin
• Liver Function Test
• Ascitic Fluid Analysis.
• Abdominal X-ray
• Ultrasonography

Final Diagnosis

Management

Source: Angel's CONCISE CLINICAL METHODS