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
o
o
o
o
Leg swelling
Breathlessness
Chest pain
Liver features:
Loss of appetite
Hematemesis/ Malena
Constipation/ Obstipation
Renal:
Oliguria
Puffiness of face
Frothy urine(Nephrotic syndrome)
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)
Jaundice
Duration
Itching
Colour of urine/ Stools
o
o
Any fever with rigor
Treatment taken
Stools:
Frequency
Colour(dark/ tarry black/ pale)
Consistency(Solid/ liquid)
Nature(Sticky/mucoid)
Associated pain
Blood streaks
Mass in abdomen
Site
Duration
Progression
Associated pain
Negative History: o
o
o
o
Fever
Duration/ Time of occurrence
Grade (high/low)
Nature(continuous / remittent)
Associated with rigors/ sweating
Upper GIT:
Dysphagia(solids/liquids/both)
Heart burn
Vomiting
Urinary Tract
Dysuria
Pain/Burning micturition
Oliguria
Hematuria
Frequency
Fever with rigor
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
o
o
o
o
o
o
o
o
Eye:
Bitot spots(Vit A)
Sub conjunctival haemorrhage(Vit K)
Colour(Anemia - pale/ jaundice - yellow)
Metabolism(KF ring/ ring/ wilson’s/ xanthelasma - fat)
Face:
Medial supraciliary madarosis
Sunken eyes, cheeks
Loss of facial hair
Parotid enlargement
Mouth
Bleeding gums
Fetor hepaticus
Chest
Spider naevi
Gynaecomastia
Atrophy of breast
Loss of pectoral hair, axillary hair
Pectoral muscle atrophy
Dilated veins
Hands:
Anemia
Bounding pulse
Clubbing
Duputryen’s contracture
Flapping tremor/ asterexis
Erythema palmar
Leuconychia
Abdomen:
Distension
Dilated veins(caput medusa)
Testis:
Atrophy
Pubic hairloss
Tumour
Lower limbs:
Pedal oedema
Chronic leg ulcers
General:
Markers of TB
Markers of HIV
Pruritis/spiderman appearance
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
o
Standing position o
o
Divarication of recti Dilated veins
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)
o
NVBS, Basal crepitation(PE, TB)
RS: CNS: o
Normal (Hepatic encephalopathy, Peripheral neuropathy)
Diagnosis: Chronic decompensated liver disease with portal hypertension and ascites
