Transcript ppt.file
HISTORY TAKING DR.H.N.SARKER MBBS,FCPS,MACP(USA), MRCP(LONDON). 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. Acquiring the history Before initiating the history taking, think for a few seconds and make a list of differential diagnosis in your mind. 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). 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 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 monthswhen did you last feel your health was normal?; How have you been feeling since?; Can you tell me a little more about that....? History of presenting complaint: Ask about the details of the abdominal swelling particularly• the time span-how long is the swelling? • is the swelling progressing? • whether the swelling is generalized or focal? • is there any associated pain or discomfort? • Is there any leg swelling? Other gastrointestinal symptoms indicating the cause- e.g. • Have you vomited blood (haematemesis)?- liver cirrhosis, castomach. • Have you passed black tarry stool ( melaena)?- liver cirrhosis, ca-stomach and ca colon. • Do you ever have any jaundice?- liver cirrhosis • Do 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 systemic symptoms, e.g. • Loss of weight and appetitetuberculosis, malignancy. • Fever- lymphoma, tuberculosis and malignancy. • Breathlessness as a result of the ascites and congestive cardiac failure. other causes of ascites, e.g. • symptoms suggestive of acute or chronic pancreatitis, • intra-abdominal sepsis/ infection, • hepatic vein thrombosis, • hypothyroidism. System review• Cough, haemoptysis- tuberculosis, malignancy. • Chest pain,palpitation- congestive cardiac failure. • Altered sleep rhythm,alteration of conscious level - liver cirrhosis Past medical history• H/o viral hepatitis-- liver cirrhosis • Past history of TB, contact with TB pt in home and workplace • History of IHD, HTN,DM. • History of renal disease. 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 tuberculosis, colon cancer. Drug history: • Ask about about current and previous medications whice may liver disease e.g. MTX or nephritic syndrome e.g. ACEi. Social history: • • • • Alcohol history Smoking history Sexual history Occupational history Vaccination history: Hepatitis B vaccination Physical examination Do the general examination with special attention to• • • • Appearance- hepatic facies- liver cirrhosis Puffy face-nephrotic syndrome Anaemia Cutaneous stigmata of liver diseaseleuconychia, clubbing, palmar erythema, depuytren’s contracture, spider navi, tattoo mark, loss of hair, gynaecomastia. • Lymphadenopathy • Odema Systemic examinationAbdomen 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. Palpation- fluid thrill may be present. There may be splenomegaly, hepatomegaly and abdominal lymphadenopathy. Percussion-shifting dullness is present. Auscultation-bowel sound normal. CVS- pulse, BP, JVP and precordium Respiratory- evidence of tuberculosis, pl.effusion. NS- confusion, disorientation, apraxia, flapping tremor and planter response. Salient feature 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. 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. 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. 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.