HEPATOMEGALY

PATIENT PARTICULARS:

• Name: Mr. XYZ

• Age: 30 years
• Sex: Male
• Address: Hassan
• Education: 10th Std
• Occupation: Farmer Socio-economic Status: Class 4 of Modified BG Prasad Classification

Date of admission : 21 December 2020

Date of examination: 23 December 2020

CHIEF COMPLAINTS:

• Distension of Abdomen since 1 month

• Vomiting since 1 week
• Yellowish discolouration of skin and eyes since 1 week

HISTORY OF PRESENTING ILLNESS

The patient was apparently alright 1 month ago. Then he developed distension of abdomen which was
insidious in onset, gradually progressive, painless and generalised distension. There are no aggravating
or relieving factors.

1. No H/o pain abdomen

2. No H/o swelling of lower limbs, facial puffiness, oliguria.
3. No H/o difficulty in breathing, orthopnea, PND
4. Patient also complains of vomitting, one episode per day since 1 Week, non yellowish in colour,
approximately 100 ml in quantity, non blood stained, non bilious and non foul smelling.
5. No H/o blood in stools

The patient also gives history of yellowish Discolouration of skin and eyes since 1 week,

• Acute in onset, gradually progressive

• first noticed in the eyes by patient atrenders
• No H/o generalised itching, clay coloured stools
• H/o high coloured urine since 1 week

History of decreased apetite since 2 months

• No H/o unintentional weight loss, easy fatiguability

• No H/o fever
• No H/o altered sleep-wake pattern, day time drowsiness
 • No h/o hematemesis, bloody in stools, melena

PAST HISTORY:

H/o similar complaints of abdominal distension, vomiting and yellowish discolouration of skin and eyes 8
months back for which he was admitted to the hospital ward and treated with medications:

• Ursodeoxycholic acid(300mg)
• Sylibon 70mg
• Neurobion

He was relieved and dicharged after 1 week

• No H/o Hypertension, Diabetes mellitus, asthma, TB, epilepsy

• No H/o chronic drug intake, blood transfusion, tattooing, IV drug abuse
• No H/o intake of any herbal medicine
• No H/o surgeries in the past

FAMILY HISTORY: No H/o similar complaints in the family.

PERSONAL HISTORY:

• Diet – Mixed
• Appetite-Reduced
• Sleep – Undisturbed
• Bowel and bladder movements – Regular and normal.
• H/o alcohol consumption since 5 years-Brandy 300g/day. Last drink was consumed 1 week ago.
• H/o smoking since 5 years-10 cigarettes/day- 2.5 pack years
• No H/o high risk sexual behaviour

SUMMARY:

Here is a 26 yr old gentleman who has a history of alcohol consumption and smoking since 5 years
comes with complaints of generalised distension of abdomen since 1 month, vomiting and yellowish
discolouration of eyes and skin since week. There is also history of similar complains 8 months ago which
was treated and relieved.

I would like to consider DECOMPENSATED CHRONIC LIVER DISEASE SECONDARY TO ETHANOL

CONSUMPTION
GENERAL PHYSICAL EXAMINATION

The patient is a middle aged male, moderately built and poorly Nourished, is conscious, co-operative
and well oriented to time, Place and person.

VITALS:

• Pulse-70 bpm normal in rhythm, character and volume, with no vessel wall thickening , there is
no radio-radial or radio-femoral Delay.
• Respiratory rate-16 cpm
• blood pressure-120/80 mmhg (measured in right arm in
• Temperature- 98.6 F (measured in the axilla)

Height-170 cms

Weight-61 kg

BMI-21.11 km

• Icterus- Present
• Pallor, Cyanosis, Clubbing, Lymphadenopathy. Edema: Not present

HEAD TO TOE EXAMINATION:

• Hair- Sparse
• Eyes- Icterus present, No pallor
• Yellowish pigmentation of skin seen
• Resting course tremors of hands is present
• Parotid Swelling, Spider nevi, Palmar erythema, white nails flapping tremors, loss of axillary and
pubic hair, dupuytren contracture, gynaecomastia , testicular Atrophy: Nit seen

PER ABDOMEN EXAMINATION:

The patient is exposed from nipples to mid-thigh region and examined in Supine position

INSPECTION:

• Generalized distension of abdomen seen

• Umbilicus is central in position and inverted
• Corresponding quadrants move equally with respiration
• Dilated veins are seen on both sides of the abdomen No scars, sinuses
• Hernial orifices are intact
• External genitalia appear normal
PALPATION:

1. Superficial Palpation -No local rise of temperature or tenderness.

2. Deep Palpation-
• -No guarding, rigidity
• -Liver is palpable, size about 10 cm below the costal margin, firm in consistency, smooth surface,
rounded borders.
• -Spleen is palpable 2cm below the costal margin by dipping method, non tender
• Kidneys not palpable

Measurements:

• Abdominal girth: 96 cm
• Xiphysternum to umbilicus: 20 cm
• Umbilicus to Pubic Symphysis: 25cm
• Umblicus to Anterior superior iliac spine

PERCUSSION:

• Liver dullness
-Upper border-Fifth right intercostal space on full Expiration
-Lower border: Dullness extends 10 cm below the right costal margin on mid clavicular line on
full expiration
• Liver span: Right lobe- 20 cm and Left lobe-11 cm
• Shifting dullness-Present.

AUSCULTATION:

• Normal bowel sounds are heard

• No venous hum or arterial bruit
• No bruit heard over liver or spleen

SYSTEMIC EXAMINATION:

1. Cardio-vascular System : S1 and 52 heard. No murmurs heard. No additional sounds beard.

2. Respiratory System: Normal vesicular breath sounds heard. Equal bilateral air entry. No added
sounds.
3. Per abdomen : Soft, no tenderness elicited. No mass felt and no organomegaly. Bowel sounds
heard.
4. Central Nervous System : No abnormality detected. Higher mental functions normal
PROVISIONAL DIAGNOSIS:

Decompensated Chronic Liver disease with moderate Ascites and Portal Hypertension with no features
of Hepatic Encephalopathy with CTP Score ‘C’ probably due to Chronic ethanol consumption