PERSONAL HISTORY

A male patient FAA, 30 years old, married & has 1 child ( 1 year old ), living in Banha
& has been always living there. He is an employee & has no special habits of medical
importance.

COMPLAINT
Pain ( heaviness ) in the left upper abdomen.

PRESENT HISTORY
The condition started 6 years ago by the gradual onset & stationary course of dragging pain
( heaviness ) in the left hypochondrium with no special radiation. The pain was continuous
& stationary in severity. It was not related to meals BUT used to increase in severity on
exertion & to improve by rest. It was not associated with any other symptoms.

Two months later, the patient started to develop generalized abdominal distension of gradual
onset & prgressive. He sought medical advice & was admitted to hospital where some
investigations were done in the form of: routine laboratory workup ( urine, stools, CBC,
renal & liver functions, & blood glucose ), together with abdominal ultrasonography and
UPPER ENDOSCOPY which revealed early oesophageal varices that did not need
Injection sclerotherapy.

He was told to have ascites but it was not associated & not followed by oedema of LLs.
He was given treatment in the form of: diet control & diuretics (spironolactone & frusemide).
His ascites regressed on this treatment over 4 weeks after which he was discharged and
maintained on minimal doses of diuretics.

Six months later, he went for follow up and investigations were done which revealed the
complete disapperance of ascites & so the diuretics were discontinued and the patient’s
condition is stationary up till now.

There were no mouth troubles, no dysphagia, no odynophagia, no upper GIT symptoms

( no heart burn, no acid reflux, no dyspepsia, no anorexia, no nausea, no vomiting ),
no lower GIT symptoms ( no diarrhea, no constipation, no altered bowel habits, no
tenesmus ), no bleeding manifestations ( no hematemesis, no melena, no hematochezia ),
no hepatobiliary symptoms ( no jaundice, no change in the colour of urine or stools, no pain
or colic in the right hypochondrium, no itching ), no urinary symptoms.

There were no symptoms of other symptoms affection.

There is no history of DM or Hypertension.

PAST HISTORY
There is past history of Bilharziasis 12 years ago for which the patient received
anti-Bilharzial ttt in the form of: Praziquantel ( 4 tablets once ).

FAMILY HISTORY
Irrelevant.