1. 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.

2. 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

3. 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

4. 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

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

6. 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 .

7. 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

8. 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

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

10. 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.

11. 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

12. 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

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

14. 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

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