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Presentation of History

Presentation of History. DR.H.N.SARKER MBBS,FCPS,MACP(USA) MRCP(LONDON) ASSOCIATE PROFESSOR MEDICINE. Presentation of History.

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Presentation of History

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  1. Presentation of History DR.H.N.SARKER MBBS,FCPS,MACP(USA) MRCP(LONDON) ASSOCIATE PROFESSOR MEDICINE

  2. Presentation of History • Mr.Rahman,50 yrs old farmer, nonsmoker, nonalcoholic, nondiabetic,nonhypertensive hailing from maderipur has got himself admitted into this hospital with chief complaint of 1) gradual swelling of abdomen for 3 months.

  3. H/o Present illness- According to the patient’s statement he was reasonably well 3 months back. Then he noticed swelling of the abdomen which increases gradually over the 3 months. The swelling is associated with little discomfort, especially after meal but no pain.

  4. H/o Present illness- The abdominal swelling is not associated with swelling of the legs, face and he is not breathlessness, no vomiting of blood and passage of tarry coloured stool.

  5. H/o Present illness- The pt gives no history of weight loss, fever, chest pain, palpitation but noticed change of sleep pattern.

  6. H/o Past illness- The pt. has no past history of tuberculosis or contact with known tuberculous patient and ingestion of raw milk. He has no history of heart disease, hypertension, renal disease but he suffered from viral hepatitis 7 yrs back but he does not know viral status.

  7. Family history- He is living with his wife and one son and two daughters, all of them are healthy. No family history of liver disease, colonic carcinoma and heart disease.

  8. Drug history- The patient is not taking any medication- prescribed or non-prescribed. No history of allergy to any drug.

  9. Social history- He is a farmer and his monthly income is 5000 tk per month living in a kacha house but using sanitary latrine and drinking tube well water. He is non-smoker and non-alcoholic. No history of extra marital sexual exposure.

  10. Immunization history- He is not HBV vaccinated.

  11. Physical examination • General examination- General examination reveals that the patient is ill-looking having hepatic facies. There is no anaemia, jaundice, cyanosis, clubbing, koilonychias, leuconychia, palmar erythema, Depuytrens contracture but he has 4-5 spider navi in the upper chest.

  12. Physical examination General examination- He has no gynaecomastia, dependent oedema. His pulse is 80 beats per minute, BP-130/80 mm of hg, Resp. rate-20/min. He is afebrile.

  13. Systemic examination- Alimentary system- on inspection the abdomen is distended, flanks are full, umbilicus is everted and centrally placed. There is no engorged vein. On deep palpation, liver is not palpable.

  14. Alimentary system- spleen is palpable 5 cm from the anterior axillary line along its long axis, surface is smooth, firm in consistency, nontender, notch is present, insinuation test is negative.

  15. Alimentary system- There is ascites as evidenced by shifting dullness but fluid thrill is absent. Normal bowel sound on auscultaion.

  16. Cardiovascular system- no abnormality on inspection, palpation and auscultation. • Respiratory system- normal. • Nervous system- normal • Locomotor system- normal

  17. Provisional diagnosis- So my provisional diagnosis is Chronic liver disease.

  18. THANK YOU

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