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
  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

  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 STD’s
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/wilson’s 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
 o Eye:
 Bitot spots(Vit A)
 Sub conjunctival haemorrhage(Vit K)
 Colour(Anemia - pale/ jaundice - yellow)
 Metabolism(KF ring/
ring/ wilson’s/ 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
 Duputryen’s 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
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 Joseph’s 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(C ushing’s - purple strine)
o Head rising
o Divarication of recti
o Standing position
o Dilated veins
o External Genitalia
o Cough impulse
o Genitalia normal

Palpation:

1. Superficial palpation

o Warmth
o Tenderness
o Thrills
2. Deep palpation

o Liver:

A tender/non tender swelling is palpable…………………cm 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)
( 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 border
o 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 Traube’
Traube’s space
 Kidney
o Colonic band of resonance

Auscultation:

 Bowel sounds:
o 10 to 15/min small bowel
o 3 to 5/min large bowel
  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