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 STDs
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/wilsons 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/ wilsons/ 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
Duputryens 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 Josephs 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(Cushings - 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 palpablecm 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) 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 Traubes 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