1. HISTORY TAKING DR.H.N.SARKERMBBS,FCPS,MACP(USA),MRCP(LONDON).

2. Case history- Mr.Rahman,50 yrs has been presented to you with swelling of the abdomen for 3 months. Case history- Mr.Rahman,50 yrs has been presented to you with swelling of the abdomen for 3 months. C/C. swelling of the abdomen for 3 months. C/C. swelling of the abdomen for 3 months.

3. Acquiring the history Acquiring the history Before initiating the history taking, think for a few seconds and make a list of differential diagnosis in your mind. Before initiating the history taking, think for a few seconds and make a list of differential diagnosis in your mind.

4. Such as in this case the abdominal swelling may be due to 5 Fs- fat (obesity), fluid (ascites), flatus (gaseous distention), faeces and fetus (not in this case).

5. Most common cause of abdominal swelling is ascites, so the differential diagnosis may be Most common cause of abdominal swelling is ascites, so the differential diagnosis may be Cirrhosis of liver Congestive cardiac failure Abdominal malignancy Abdominal tuberculosis Nephritic syndrome

6. Presenting complaint: Presenting complaint: Begin with an open question, without focusing on the abdominal swelling. `I understand from you that you haven’t been feeling so well over recent months- when did you last feel your health was normal?; How have you been feeling since?; Can you tell me a little more about that....?

7. History of presenting complaint: History of presenting complaint: Ask about the details of the abdominal swelling particularly- Ask about the details of the abdominal swelling particularly- the time span-how long is the swelling? the time span-how long is the swelling? is the swelling progressing? is the swelling progressing? whether the swelling is generalized or focal?whether the swelling is generalized or focal? is there any associated pain or discomfort? is there any associated pain or discomfort? Is there any leg swelling?Is there any leg swelling?

8. Other gastrointestinal symptoms indicating the cause- e.g. Other gastrointestinal symptoms indicating the cause- e.g. Have you vomited blood (haematemesis)?- liver cirrhosis, ca- stomach.Have you vomited blood (haematemesis)?- liver cirrhosis, ca- stomach. Have you passed black tarry stool ( melaena)?- liver cirrhosis, ca-stomach and ca colon.Have you passed black tarry stool ( melaena)?- liver cirrhosis, ca-stomach and ca colon. Do you ever have any jaundice?- liver cirrhosisDo you ever have any jaundice?- liver cirrhosis

9. Do you notice recent change in your bowel habit?- ca colon and abdominal tuberculosisDo you notice recent change in your bowel habit?- ca colon and abdominal tuberculosis Do you notice any nodular swelling in the body?-lymphoma, malignancy and disseminated tuberculosis Do you notice any nodular swelling in the body?-lymphoma, malignancy and disseminated tuberculosis

10. systemic symptoms, e.g. systemic symptoms, e.g. Loss of weight and appetite- tuberculosis, malignancy. Loss of weight and appetite- tuberculosis, malignancy. Fever- lymphoma, tuberculosis and malignancy.Fever- lymphoma, tuberculosis and malignancy. Breathlessness as a result of the ascites and congestive cardiac failure.Breathlessness as a result of the ascites and congestive cardiac failure.

11. other causes of ascites, e.g. other causes of ascites, e.g. symptoms suggestive of acute or chronic pancreatitis,symptoms suggestive of acute or chronic pancreatitis, intra-abdominal sepsis/ infection,intra-abdominal sepsis/ infection, hepatic vein thrombosis,hepatic vein thrombosis, hypothyroidism.hypothyroidism.

12. System review- System review- Cough, haemoptysis- tuberculosis, malignancy.Cough, haemoptysis- tuberculosis, malignancy. Chest pain,palpitation- congestive cardiac failure.Chest pain,palpitation- congestive cardiac failure. Altered sleep rhythm,alteration of conscious level - liver cirrhosisAltered sleep rhythm,alteration of conscious level - liver cirrhosis

13. Past medical history- Past medical history- H/o viral hepatitis-- liver cirrhosisH/o viral hepatitis-- liver cirrhosis Past history of TB, contact with TB pt in home and workplacePast history of TB, contact with TB pt in home and workplace History of IHD, HTN,DM.History of IHD, HTN,DM. History of renal disease.History of renal disease.

14. Relevant family history: Relevant family history: Ask about a family history of liver disease(Haemachromatosis, Wilson’s disease), hepatitis(Hepatitis B may be vertically transmitted).Ask about a family history of liver disease(Haemachromatosis, Wilson’s disease), hepatitis(Hepatitis B may be vertically transmitted). Ask about a family history of tuberculosis, colon cancer.Ask about a family history of tuberculosis, colon cancer.

15. Drug history: Drug history: Ask about about current and previous medications whice may liver disease e.g. MTX or nephritic syndrome e.g. ACEi.Ask about about current and previous medications whice may liver disease e.g. MTX or nephritic syndrome e.g. ACEi. Social history: Social history: Alcohol historyAlcohol history Smoking historySmoking history Sexual historySexual history Occupational historyOccupational history

16. Vaccination history: Vaccination history: Hepatitis B vaccination Hepatitis B vaccination

17. Physical examination- Do the general examination with special attention to- Do the general examination with special attention to- Appearance- hepatic facies- liver cirrhosisAppearance- hepatic facies- liver cirrhosis Puffy face-nephrotic syndromePuffy face-nephrotic syndrome AnaemiaAnaemia Cutaneous stigmata of liver disease- leuconychia, clubbing, palmar erythema, depuytren’s contracture, spider navi, tattoo mark, loss of hair, gynaecomastia.Cutaneous stigmata of liver disease- leuconychia, clubbing, palmar erythema, depuytren’s contracture, spider navi, tattoo mark, loss of hair, gynaecomastia. LymphadenopathyLymphadenopathy OdemaOdema

18. Systemic examination- Abdomen- Inspection-distended abdomen, flanks are full, umbilicus is centrally placed and everted. May have recti diverication. May have engorged veins with normal direction of flow. Inspection-distended abdomen, flanks are full, umbilicus is centrally placed and everted. May have recti diverication. May have engorged veins with normal direction of flow.

19. Palpation- fluid thrill may be present. There may be splenomegaly, hepatomegaly and abdominal lymphadenopathy. Palpation- fluid thrill may be present. There may be splenomegaly, hepatomegaly and abdominal lymphadenopathy. Percussion-shifting dullness is present. Percussion-shifting dullness is present. Auscultation-bowel sound normal. Auscultation-bowel sound normal.

20. CVS- pulse, BP, JVP and precordium CVS- pulse, BP, JVP and precordium Respiratory- evidence of tuberculosis, pl.effusion. Respiratory- evidence of tuberculosis, pl.effusion. NS- confusion, disorientation, apraxia, flapping tremor and planter response. NS- confusion, disorientation, apraxia, flapping tremor and planter response.

21. Salient feature Mr.Rahman,50 yrs old farmer nonsmoker, Mr.Rahman,50 yrs old farmer nonsmoker, nonalcoholic, nondiabetic,nonhypertensive hailing from maderipur has been admitted into this hospital with gradual swelling of abdomen for 3 months with little discomfort but no pain.

22. The abdominal swelling is not associated with dependent odema, facial puffiness, breathlessness, haematemesis, maelena, weight loss, fever. The abdominal swelling is not associated with dependent odema, facial puffiness, breathlessness, haematemesis, maelena, weight loss, fever. The pt gives no history of chest pain, palpitation but noticed change of sleep pattern. The pt gives no history of chest pain, palpitation but noticed change of sleep pattern.

23. The pt. has no past history of tuberculosis, heart disease, hypertention, renal disease but he suffered from viral hepatitis 7 yrs back but he does not know viral status. No significant family history, drug history and social history. The pt. has no past history of tuberculosis, heart disease, hypertention, renal disease but he suffered from viral hepatitis 7 yrs back but he does not know viral status. No significant family history, drug history and social history.

24. On examination pt. has hepatic facies, spider navi (5 in number), gynaecomastia and testicular atrophy but no other positive findings on G/E. Abdominal examination reveals ascites and splenomegaly. On examination pt. has hepatic facies, spider navi (5 in number), gynaecomastia and testicular atrophy but no other positive findings on G/E. Abdominal examination reveals ascites and splenomegaly. So my provisional diagnosis is CLD. So my provisional diagnosis is CLD.