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