Mr sekar . 37 yrs old male patient coming from madurai , working in an eversilver utensil manufacturing shop Admitted in our hospital with chief complaints of vomiting blood – 1 episode 10 days ago passing black colored stools – 10 days duration.

History of presenting illness Apparently normal until 10 days ago when he developed acute onset of hemetemesis – massive nature 500 ml . altered blood ass with giddiness and palpitations not preceded by cough, retching h/o malena+ No h/o abdominal pain/ abdominal distension No h/o jaundice/high colored urine/pruritus No h/o pedal edema/oliguria

h/o occasional gum bleeding+ No h/o epistaxis/hemoptysis/hematuria No h/o hemmorhoids/hematochezia No h/o fever No h/o cough/chestpain/dyspnoea h/o easy fatiguability No h/o loss of weight/appetite No h/o altered bowel habits No h/o confusion/altered behaviour/seizures No h/o skin rash/arthralgia/oral ulcers No h/o involuntary movements

Past history No h/o similar episodes in the past. h/o jaundice + in the past – at the age of 12 years - lasted for 1 week ..Rx with herbal tonic – got relieved in about a weeks Time h/o admission at GRH 8 months back for nonspecific complaints like tiredness, giddiness and was evaluated for severe anemia – was transfused with 1 unit of blood at that time.also told to have liver disease No h/o systemic hypertension/diabetes/Pul TB/Bronchial asthma/epilepsy in the past No h/o tattooing No h/o exposure to hepatotoxic drugs in the past

Personal history: Not an alcoholic /smoker Denies exposure to STD Family history: 5 siblings. No h/o family h/o similar illness

summary 37/m , non alcoholic with previous h/o jaundice and recently diagnosed liver disease presenting with major UGI bleed in the form of massive hemetemesis and malena .

Clinical Examination of the patient General examination Moderately built and moderately nourished conscious, oriented , afebrile No pallor, no jaundice, no cyanosis Gr II clubbing+ no Pedal edema no significant lymphadenopathy No signs of liver cell failure like jaundice, bitot spots, KF ring , liver palms, spider nevi, dupytrens contracture, parotid swelling , gynaecomastia, testicular atrophy, ascites , fetor hapticus,asterixis

Vital data Pulse : 46/mt, regular, normal volume, no specific character , felt equally in all accessible peripheral vessels BP: 130/80 mm HG in RUL supine position RR: 14 / mt, regular, abdomino thoracic Afebrile Impression: bradycardia

Examination of the oral cavity No fetor hepaticus No dental caries No oral candidiasis Tonsillar fossa and waldeyer s ring not enlarged

Examination of the abdomen Inspection: Shape of the abdomen – scaphoid All quadrants moves equally with respiration No VGP/VIP Epigastric pulsations are visible No dilated veins over abdomen/backs Oval – round shaped Healed scars + No sinuses Hernial orifices are free Umbilicus – shape/position normal Flanks are free External genitalia are normal.

Palpation: Not warm , no tenderness Spleen is palpable 6 cms below the left costal margin in the left midclavicular line . Non tender , firm in consistency, margins are rounded , splenic Notch could be made out. Moves with respiration and not able to insuinate fingers between the spleen and the left subcostal Margin and able to get above the swelling . Not bimanually palpable and not ballotable No other organomegaly/mass made out

Percussion: Liver dullness start in right 5th ICS in the midclavicular line and ends at the right subcostal margin Tidal percussion is +ve Liver span is 10 cms Spleen is dull to percussion. No colonic band of resonance No shifting dullness Puddle s sign – ve

Auscultation: ? Venous hum over the epigastrium No bruit/rub Bowel sounds are heard normally

Other systems CVS: JVP – not elevated First and second heart sounds are normally heard No murmurs RS: trachea in midline NVBS heard in all areas Fine crackles in rt infra scapular and rt infra axillary region CNS: No asterixis No FND

Final diagnosis Chronic liver disease - compensated Portal hypertension - UGI bleed No e/o SBP/hepatic encepahalopathy/Hepatorenal/ hepatopulmonary syndrome