Dravergonz’13
Dravergonz’2013
MEDICINE
EXAM
CASES
N.DILIP JAIVANTH
K.G.AJAEY
Tirunelveli Medical College
Dravergonz’13
1. CNS
 Cerebrovascular accident
2. CARDIOVASCULAR SYSTEM
 Mitral regurgitation
 Mitral stenosis
 Aortic regurgitation
 Aortic stenosis
3. RESPIRATORY SYSTEM
 Pleural effusion
 Fibrosis
 Collapse(atelectasis)
 Bronchiectasis
4. GIT
 Ascites with cirrhosis of liver
 Hepatomegaly
 Spleenomegaly
 Hepatospleenomegaly
Dravergonz’13
1. CEREBROVASCULAR ACCIDENT
Name: Mr.Arumugam
Age: 54 yrs
Sex: male
Place: Kadayam
Occupation: Farmer
COMPLAINTS:
 Difficulty in using his ® upper and lower limb
 Deviation of angle of mouth to the left
X 3 days
X 3 days
H/O PRESENTING ILLNESS:
The patient was apparently normal before 3 days. He
went to sleep normally. On the next day morning, at about 5 am,
when he woke up, he found difficulty in using his ® upper and lower
limb with deviation of angle of mouth to the left. The weakness is
confined more to the upper limb. The weakness is sudden in onset,
progressive and attained its peak 3 hrs after the onset. This episode is
not accompanied with headache, vomiting, blurring of vision or loss
of consciousness. He was immediately taken to the nearby PHC and
was referred to TvMCH. The patient is now improving.
Dravergonz’13
 H/O difficulty in raising his ® upper limb above the head
 H/O difficulty in mixing the food(/ using the hand(left) for
toilet purpose)
 H/O difficulty in getting up from squatting position
 H/O difficulty in holding the slippers
 No H/O difficulty in raising the head from the bed
 No H/O difficulty in turning the head from side to side
 No H/O difficulty in rolling over the bed
 No H/O disturbance in consciousness or orientation
 No H/O memory, speech, behavioural or emotional
Motor
system
Higher
functions
Disturbances
 No H/O disturbance in appreciating smell
 No H/O blurring of vision or disturbance in appreciating colours
 No H/O drooping of lids, double vision or difficulty in moving the
eye in all directions
 No H/O difficulty in appreciating sensation over the face or
difficulty in chewing
 H/O deviation of angle of mouth to the left
 H/O stasis of food in the mouth and drooling of saliva
 No H/O hard of hearing, tinnitus or vertigo
 No H/O nasal regurgitation of food or nasal twang of voice
 No H/O difficulty in turning the head from side to side
 No H/O difficulty in rolling over the bed
 No H/O difficulty mixing the food or initiate swallowing
Dravergonz’13
 No H/O difficulty in appreciating the sensation of clothes
 No H/O difficulty in appreciating hot and cold
Sensory
system
 No H/O difficulty in appreciating pain
 No H/O tingling or numbness
 No H/O involuntary movements
Cerebellar
functions
 No H/O difficulty in reaching the objects
 No H/O difficulty in bringing food to the mouth
 No H/O difficulty in initiating micturition
 No H/O frequency, urgency or incomplete evacuation of bladder Autonomic
function
 No H/O bowel disturbances
 No H/O injury to the head
 No H/O fever with neck stiffness
Aetiological
history
 No H/O chest pain or palpitation
 No H/O diarrhoea or ear discharge
(Don’t ask for the history of recent vaccination as the anti-rabies
vaccine derived from the sheep’s brain are not used now-a-days)
PAST HISTORY


No H/O similar complaints in the past
No H/O Transient Ischaemic Attacks(TIA) or Reversible
Ischaemic Neurological Deficits(RIND)

No H/O diabetes, hypertension, tuberculosis, bronchial
asthma or epilepsy

No H/O STD exposure
Dravergonz’13


No H/O any drug intake
(In females ask for OCP intake)
PERSONAL HISTORY:


The patient is non-vegetarian
Chronic smoker
 For the past 30 years
 Smokes 20 beedi/day(1 pack)
 Smoke years20X30600
 Pack years1X3030

Chronic alcoholic for the past 30 years
FAMILY HISTORY:

No H/O similar complaints among family members
SOCIOECONOMIC HISTORY:

According to modified Kuppusamy scale, the patient
belongs to CLASS 4(Upper lower socioeconomic class)
Dravergonz’13
SUMMARY:
A 54 year old male, a chronic smoker and an alcoholic,
came with complaints of difficulty in using his ® upper and lower
limb with deviation of angle of mouth to the left for the past 3
days. This episode is sudden in onset, progressive and is not
accompanied by vomiting, headache, blurring of vision or loss of
consciousness. This is a case of Cerebrovascular accident probably
of thrombotic aetiology.
GENERAL EXAMINATION
The patient is,
Conscious, communicative, co-operative
Oriented
Afebrile
Moderately built and moderately nourished
Not anaemic
Not jaundiced
No cyanosis
No clubbing
No pedal oedema
No significant generalised lymphadenopathy
Dravergonz’13
Markers: No markers of atherosclerosis
No markers of syphilis
No neurocutaneous markers
VITALS:
 PULSE:








Rate: 72/minute
Rhythm: regular
Volume: normal volume
Character: no specific character
No radio femoral delay
No vessel wall thickening
Felt equally in all peripheries
CAROTIDS ARE FELT NORMALLY ON BOTH
SIDES
 BLOOD PRESSURE:
 130/90 mmHg
 Measured in the left upper limb with patient in
supine position
 RESPIRATORY RATE:
 Rate: 18/minute
 Rhythm: regular
 Type: Abdomino-thoracic type
 TEMPERATURE:
 37° C
Dravergonz’13
EXAMINATION OF CNS
1.HIGHER FUNCTIONS:
 The patient is right handed
 Consciousness: normal
 Orientation to
 Time
 Place
Normal
 person
 Behaviour: well behaving
 Memory
 recent
 Immediate Intact
 remote
 Speech
 spontaneous speech
 Comprehension
 Naming
Normal
 Repitition
 Reading
 Word output
 Disarticulation of speech is
present
 Sleep pattern: normal
Dravergonz’13
 Emotional status: normal
 No delusion, illusion or hallucination
2. CRANIAL NERVES:
1.
CRANIAL NERVE
Olfactory nerve
RIGHT
Able to
perceive smell
LEFT
Able to
perceive smell
2.
Optic nerve
6/60
6/36
 Visual acuity
 Colour vision
normal
normal
 Field of vision
 Light reflex
3,4,6 Oculomotor, trochlear,
abducent nerve
normal
normal
 Ocular movement
no drooping
no drooping
 Drooping of lids
present
present
 Light reflex
5.
Trigerminal nerve
normal
normal
 Sensation over the
face
normal power normal power
 Masseter and
temporalis
present
present
 Corneal and
conjuctival reflex
 Patient is able to open the mouth against resistance
7.
Facial nerve
 UMN type of Right facial nerve palsy is present
8.
Vestibulo-cochlear nerve
 Rinnie’s test
 Weber’s test
positive
Positive
No lateralisation
Dravergonz’13
9,10
11.
Glossopharyngeal, vagus
nerve
 Uvula is in midline
 ‘Ah’ test
Normal
elevation
present
 Palatal/pharyngeal
reflex
Accessory spinal nerve
 Sternomastoid
Able to shrug the shoulders
against resistance
Able to turn the face against
resistance
 temporalis
12.
Normal
elevation
present
Hypoglossal nerve
 Able to protrude the tongue
 No deviation
 No fibrillation
 Power- normal
3. SPINOMOTOR SYSTEM:
1. BULK:
RIGHT
LEFT
32
33
23
24
LOWER LIMB
 THIGH
48
49
 LEG
36
37
UPPER LIMB
 ARM
 FORE ARM
No obvious wasting in the limbs
Dravergonz’13
2. TONE:
UPPER LIMB
LOWER LIMB
RIGHT
Hypertonia of flexors
Hypertonia of
extensors
LEFT
Normal tone
Normal tone
3. POWER:
RIGHT
LEFT
UPPER LIMB
 Shoulder joint
 Adduction
 Abduction
 Flexion
 Extension
 Medial rotation
 Lateral rotation
 Elbow joint
 Flexion
 Extension
 Wrist joint
 Dorsiflexion
 Palmarflexion
 Hand grip
3
2
3
2
3
3
5
5
5
5
5
5
3
2
5
5
2
3
60%
5
5
100%
4
4
5
5
LOWER LIMB
 Hip joint
 Adduction
 Abduction
Dravergonz’13
 Flexion
 Extension
 Knee joint
 Flexion
 Extension
 ankle joint
 Dorsiflexion
 Plantarflexion
4
4
5
5
4
4
5
5
2
3
5
5
4.REFLEXES:
1.SUPERFICIAL
REFLEXES
 Corneal
 Conjuctival
 Palatal
 Pharyngeal
 Abdominal
 Cremastric
 plantar
2.DEEP TENDON
REFLEXES
 biceps
 triceps
 supinator
 knee jerk
 ankle jerk
RIGHT
LEFT
Present
Present
Absent
extensor
Very brisk
Brisk
Brisk
Very brisk
Brisk
ANKLE CLONUS is present.
flexor
Present
Present
Present
Present
present
Dravergonz’13
4. CO-ORDINATION SYSTEM:
RIGHT
LEFT
UPPER LIMB
 Finger to nose
test
 Finger nose
finger test
 Draw circle in
air
Unable to do
because of weakness
Able to do
LOWER LIMB
 Heel knee test
 Draw circle in
air
Unable to do
because of weakness
Able to do
5. SENSORY SYSTEM








Fine touch
Crude touch
Pressure
Pain
Temperature
Vibration
Proprioception
Cortical sensation
 Tactile localisation
 Tactile discrimination
 Sterignosis
 graphesthesia
RIGHT
LEFT
Normal
normal
Dravergonz’13
OTHER SYSTEM EXAMINATION:
CVS:
 S1, S2 heard
 No added sounds
 No murmur
RS:
 Normal vesicular breath sounds heard
 No added sounds
GIT:
 Normal bowel sounds heard
 No oranomegaly
 No free fluid
DIAGNOSIS:
A case of Cerebrovascular accident with right sided
hemiparesis involving the left sided internal capsule probably the
lenticulostriate branch of left middle cerebral artery and the aetiology
is probably thrombotic.
Dravergonz’13
2. PLEURAL EFFUSION
Name: Mr. Natraj
Age: 46 years
Sex: Male
Place: Tirunelveli town
Occupation: works in cotton mill
COMPLAINTS:
 Cough
 Chest pain
 Difficulty in breathing
X
X
X
15 days
15 days
10 days
H/O PRESENTING ILLNESS:
The patient was apparently normal before 15 days,
after which he developed,
CHIEF RESPIRATORY COMPLAINTS
 Cough
1. Cough with expectoration
 Duration: 15 days
2. Chest pain
 Onset: gradual, progressive
3. Breathlessness
 Type: dry
4. Haemoptysis
5. Wheeze
 Nature: intermittent
 Associated with chest pain
 Aggravated during inspiration
 No relieving factors
 No radiation, seasonal or positional variation
 Chest pain
 Site: confined to the right side
 Duration:15 days
Dravergonz’13






Onset: gradual, progressive
Type: pricking
Nature: intermittent
Aggravated during inspiration
No relieving factors
No radiation
 Difficulty in breathing
 Duration: 10 days
 Onset: gradual, progressive
 Grade 3 (MMRC grading)
 Nature: continuous
 Aggravated during walking
 No relieving factors
 No variability
 Not associated with orthopnoea or Paroxysmal
Nocturnal dyspnoea
 No H/O haemoptysis
 No H/O wheeze
 No H/O
 abdominal pain
 abdominal distension
 leg swelling
 palpitation
 syncope
 No H/O
 Night sweats
 Evening rise in temperature
For
cardiovascular
system
For
tuberculosis
Dravergonz’13
 No H/O




Loss of weight
Loss of appetite
Hoarseness of voice
Difficulty in swallowing
For malignancy
PAST HISTORY:


No H/O similar complaints in the past
No H/O diabetes, hypertension, tuberculosis, bronchial
asthma or epilepsy

No H/O aspiration
PERSONAL HISTORY:


The patient is non-vegetarian
Chronic smoker
 For the past 30 years
 Smokes 20 beedi/day(1 pack)
 Smoke years20X30600
 Pack years1X3030

Occasional alcoholic
FAMILY HISTORY:
No H/O similar complaints among family members
Dravergonz’13
OCCUPATIONAL HISTORY:
The patient works in a cotton mill.
SOCIOECONOMIC HISTORY:

According to modified Kuppusamy scale, the patient
belongs to CLASS 4(Upper lower socioeconomic class)
CONTACT HISTORY:
No history of contact with tuberculosis patients
SUMMARY:
A 46 year old male, a chronic smoker, came with complaints of
chest pain, cough and breathlessness for the past 15 days. The
system involved is respiratory system.
GENERAL EXAMINATION
The patient is,
Dyspnoeic at rest
Conscious
Oriented
Afebrile
Moderately built and moderately nourished
Not anaemic
Dravergonz’13
Not jaundiced
No cyanosis
No clubbing
No pedal oedema
No significant generalised lymphadenopathy
Markers: No markers of Tuberculosis
No markers of SVC obstruction
No markers of carbon dioxide retention
No markers of HIV
No markers of Horners syndrome
VITALS:
 PULSE:
 Rate: 84/minute
 Rhythm: regular
 Volume: normal volume
 Character: no specific character
 No radio femoral delay
 No vessel wall thickening
 Felt equally in all peripheries
 BLOOD PRESSURE:
 130/90 mmHg
 Measured in the left upper limb with patient in
supine position
 RESPIRATORY RATE:
 Rate: 26/minute
 Rhythm: regular
 Type: Abdomino-thoracic type
Dravergonz’13
 TEMPERATURE:
 37° C
EXAMINATION OF RS
INSPECTION:
 Upper respiratory tract:
 Nasal mucosa- normal
 No nasal septal deviation
 No nasal polyps
 Oral cavity:
 Good oral hygiene
 No dental caries
 Respiratory system proper:
 Chest wall is bilaterally symmetrical and elliptical in
shape
 No chest wall and spine abnormalities like,
 Kyphosis
 Scoliosis
 Pectus excavatum/
carinatum
 Trachea appears to be deviated to the left
 Apical impulse is not visible
 Rib space is widened on the Right side
 No drooping of shoulder
Dravergonz’13
 Movements
APICAL
ANTERIOR
POSTERIOR
RIGHT
normal
Diminished
diminished
LEFT
Normal
normal
Normal
 No Supraclavicular fullness or hollowness
 No dilated veins, scars, sinuses or tapping marks
PALPATION:
 Not warm
 Non tender
 Trachea is deviated to the left
 Apical impulse is felt in the left fifth intercostal space ½
inch lateral to the midclavicular line(shifted)
 Movements:
APICAL
ANTERIOR
POSTERIOR
RIGHT
normal
Diminished
diminished
LEFT
Normal
normal
Normal
 Measurements:
 Inspiration
84
 Expiration
81
 Chest expansion
3
Hemi thorax measurement:
Inspiration
RIGHT
Expiration
Inspiration
LEFT
Expiration
42
41
42
39
Chest
expansion=1
Chest
expansion=3
Dravergonz’13
The movement is diminished on the right side
Spinoscapular
RIGHT
13
distance
LEFT
13
 No tactile fremitus
 Vocal fremitus:
AREAS
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Interscapular
infrascapular
RIGHT
Normal
reduced
reduced
reduced
reduced
Normal
reduced
reduced
LEFT
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
PERCUSSION:
 Direct percussion over the clavicle-resonant
 Kronig’s isthmus- resonant
AREAS
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Interscapular
infrascapular
RIGHT
Resonant
Stony dull
Stony dull
Stony dull
Stony dull
Resonant
Stony dull
Stony dull
LEFT
Resonant
Resonant
Resonant
Resonant
Resonant
Resonant
Resonant
Resonant
Dravergonz’13
 Tidal percussion- dull(percuss traube’s space in left
sided effusion)
 No straight line dullness
 No shifting dullness
AUSCULTATION:
AREAS
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Interscapular
infrascapular
RIGHT
NVBS
Diminished
Diminished
Diminished
Diminished
NVBS
Diminished
Diminished
LEFT
NVBS
NVBS
NVBS
NVBS
NVBS
NVBS
NVBS
NVBS
RIGHT
Normal
reduced
reduced
reduced
reduced
Normal
reduced
reduced
LEFT
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
 Vocal resonance:
AREAS
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Interscapular
infrascapular
 Succession splash- absent
 Coin test- negative
Dravergonz’13
OTHER SYSTEM EXAMINATION:
CVS:
 S1, S2 heard
 No added sounds
 No murmur
GIT:
 Normal bowel sounds heard
 No oranomegaly
 No free fluid
CNS:
 No focal neurological deficit
DIAGNOSIS:
A case of Right sided pleural effusion probably due to
tuberculous aetiology.
Dravergonz’13
3. MITRAL REGURGITATION
Name: Mr. Iyappan
Age: 46 years
Sex: Male
Place: Palayamkottai
Occupation: Shop keeper
COMPLAINTS:
 Difficulty in breathing
X
1 week
H/O PRESENTING ILLNESS:
The patient was apparently normal before 1 week,
after which he developed,
 Difficulty in breathing
 Duration: 1 week
CHIEF CARDIAC COMPLAINTS
 Onset: gradual, progressive
1. Chest pain
 Class 3 (NYHA Classification)
2. Palpitation
 Aggravated by exertion
3. Exertional dyspnoea
4. Syncope
 Relieved by rest
5. Easy fatigueability
 Associated with orthopnoea and Paroxysmal
6. Oedema
Nocturnal dyspnoea
 H/O palpitation
 Duration: 5 days
Dravergonz’13










Intermittent
irregular
Precipitated by exertion
Relieved by rest
No associated features(passing urine after an
episode of palpitation indicates supraventricular
tachycardia)
No H/O Chest pain
No H/O cough with expectoration
No H/O syncope
No H/O easy fatigueability
No H/O
 abdominal pain
 abdominal distension
 Swelling of legs
For Right heart
failure
 No H/O fever
For infective
endocarditis
 No H/O Oligurea or puffiness of face
For renal
causes
PAST HISTORY:

H/O similar complaints before 4 years. He went to GH for
the same and was diagnosed to have heart disease and was
prescribed medications.

No H/O diabetes, hypertension, tuberculosis, bronchial
asthma or epilepsy.

No history suggestive of rheumatic fever.
Dravergonz’13
PERSONAL HISTORY:


The patient is non-vegetarian
Chronic smoker
 For the past 30 years
 Smokes 20 beedi/day(1 pack)
 Smoke years20X30600
 Pack years1X3030

Occasional alcoholic
FAMILY HISTORY:
No H/O similar complaints among family members
SOCIOECONOMIC HISTORY:

According to modified Kuppusamy scale, the patient
belongs to CLASS 4(Upper lower socioeconomic class)
SUMMARY:
A 46 year old male, a chronic smoker and an alcoholic,
came with complaints of dyspnoea on exertion associated with
orthopnoea and PND and palpitation for the past 1 week with similar
complaints in the past. The system involved is cardiovascular system.
Dravergonz’13
GENERAL EXAMINATION
The patient is,
Comfortable at rest
Conscious
Oriented
Afebrile
Moderately built and moderately nourished
Not anaemic
Not jaundiced
No cyanosis
No clubbing
No pedal oedema
No significant generalised lymphadenopathy
Markers: No markers of Rheumatic heart disease
No markers of Infective endocarditis
No markers of congenital heart disease
No markers of atherosclerosis
No markers of syphilis
VITALS:
 PULSE:





Rate: 84/minute
Rhythm: irregularly irregular
Volume: variable volume
Character: no specific character
No radio femoral delay
Dravergonz’13
 No vessel wall thickening
 Felt equally in all peripheries
 Heart rate = 106
 PULSE DEFICIT= 22
 BLOOD PRESSURE:
UPPER LIMB
RIGHT
LEFT
LOWER LIMB
RIGHT
LEFT
103/90mmHg
130/90mmHg
140/96mmHg
140/96mmHg
 RESPIRATORY RATE:
 Rate: 18/minute
 Rhythm: regular
 Type: Abdomino-thoracic type
 TEMPERATURE:
 37° C
 JVP:
 Not elevated
EXAMINATION OF
CARDIOVASCULAR SYSTEM
INSPECTION:
 Chest wall is symmetrical
 No chest wall and spine abnormalities like Kyphosis,
scoliosis, Pectus excavatum or carinatum
 Apical impulse is seen in more than one space
 Trachea appears to be in midline
Dravergonz’13
 No precordial bulge
 Parasternal lift is seen
 No visible pulsations
 No scars or dilated veins
PALPATION:
 Not warm, not tender
 Apical impulse
 felt in left fifth intercostal space 1 cm
lateral to the midclavicular line
 Hyperdynamic
 A thrill is palpable in the mitral area
 Parasternal heave is present- Grade 3
 P2 is palpable in the pulmonary area
 Trachea is in midline
AUSCULTATION:
 MITRAL AREA
 S1 – soft
 S2 – loud
 No added sounds
 A high pitched soft blowing pan systolic
murmur of grade 4 is heard in the mitral area
with diaphragm of the stethoscope with patient
in the left lateral position with breath held in
Dravergonz’13
expiration and the murmur is radiated to the
axilla.
 TRICUSPID AREA
 S1 – soft
 S2 – heard
 No added sounds
 A transmitted systolic murmur is heard
 PULMONARY AREA
 S1 – soft
 S2 – loud P2
 No added sounds
 No murmur
 AORTIC AREA
 S1, S2 heard
 No added sounds
 No murmur
OTHER SYSTEM EXAMINATION:
RS:
 Normal vesicular breath sounds heard
 Basal cripitations are heard
GIT:
 Normal bowel sounds heard
 No oranomegaly
 No free fluid
Dravergonz’13
CNS:
 No focal neurological deficit
DIAGNOSIS:
It is a case of acquired valvular heart disease, a regurgitant
lesion of the mitral valve, with pulmonary hypertension
probably of rheumatic aetiology. The patient is in atrial
fibrillation (or sinus rhythm) with no signs of heart failure
or infective endocarditis.
Dravergonz’13
DESCRIPTION OF OTHER
MURMURS
Mitral stenosis:
A low pitched rough rumbling mid-diastolic murmur of grade 3
or 4 (which follows opening snap) is heard in the mitral area
with the bell of the stethoscope with patient in the left lateral
position and breath held in expiration.
Aortic stenosis:
A high pitched crescendo-decrescendo murmur of grade 3 or 4
(which follows ejection click) is heard in the aortic area with the
diaphragm of the stethoscope with patient leaning forward and
breath held in expiration and the murmur is radiated to the
carotids.
Aortic regurgitation:
A high pitched decrescendo murmur of grade 3 or 4 is heard in
the second aortic (Erb’s) area with the diaphragm of the
stethoscope with patient leaning forward and breath held in
expiration.
Dravergonz’13
3. ASCITES
Name: Mr. Marimuthu
Age: 48 years
Sex: Male
Place: Kadayam
Occupation: Mason
COMPLAINTS:
 Abdominal distension
X
15 days
H/O PRESENTING ILLNESS:
The patient was apparently normal before 15 days,
after which he developed,
 Abdominal distension
 Duration: 15 days
 Onset: gradual and progressive
 Uniform distension
 Not associated with pain
 H/O yellowish discoloration of eyes and passage of high
colour urine
 Duration: 1 month
 Normal colour stools
 Not associated with itch
 No H/O abdominal pain
 No H/O vomiting
 H/O loss of weight and loss of appetite
 No H/O fever
Dravergonz’13
 No H/O vomiting of blood or passage of black colour
stools
For renal
 No H/O puffiness of face or Oligurea
causes
 No H/O chest pain or breathlessness
 No H/O bleeding from nose or bleeding gums
 No H/O altered sleep pattern
For cardiac
causes
Complications
of liver
dysfunction
PAST HISTORY:


No H/O similar complaints in the past
No H/O diabetes, hypertension, tuberculosis, bronchial
asthma or epilepsy.



No H/O tattooing
No H/O previous blood transfusions
No H/O previous abdominal surgeries
PERSONAL HISTORY:


The patient is non-vegetarian
Chronic smoker
 For the past 30 years
 Smokes 20 beedi/day(1 pack)
 Smoke years20X30600
 Pack years1X3030
Dravergonz’13


Chronic alcoholic
 For the past 30 years
 Type: Brandy
 180 ml per day
 4 to 5 times a week
No H/O drug abuse
FAMILY HISTORY:
No H/O similar complaints among family members
SOCIOECONOMIC HISTORY:

According to modified Kuppusamy scale, the patient
belongs to CLASS 4(Upper lower socioeconomic class)
SUMMARY:
A 48 year old male, a chronic smoker and an alcoholic,
came with complaints uniform abdominal distension and jaundice for
the past 15 days. The system involved is hepatobiliary system.
GENERAL EXAMINATION
The patient is,
Conscious
Oriented
Afebrile
Moderately built and moderately nourished
Anaemic
Dravergonz’13
Jaundiced
No cyanosis
No clubbing
Bilateral pitting Pedal oedema is present
No significant generalised lymphadenopathy
Markers: Markers of liver cell failure
Jaundice
Parotid enlargement
are present
Flapping tremor
Ascites
VITALS:
 PULSE:
 Rate: 84/minute
 Rhythm: regular
 Volume: normal volume
 Character: no specific character
 No radio femoral delay
 No vessel wall thickening
 Felt equally in all peripheries
 BLOOD PRESSURE:
 130/90 mmHg
 Measured in the left upper limb with patient in
supine position
 RESPIRATORY RATE:
 Rate: 26/minute
 Rhythm: regular
 Type: Thoraco-abdominal type
Dravergonz’13
 TEMPERATURE:
 37° C
 JVP: not elevated
EXAMINATION OF ABDOMEN
INSPECTION:
 Oral cavity:






Lips- normal
Buccal mucosa- normal
Tongue- normal
Teeth- normal
Gums- normal
No halitosis
 Abdomen proper:
 Abdomen is uniformly distended
 Flanks full
 All the quadrants of the abdomen moves equally with
respiration
 Umbilicus




Shifted downwards
Flushed to the surface
Appears as a transverse slit
No dilated veins or discoloration around the
umbilicus
 No nodules
 Skin over the abdomen is stretched and shiny
 No dilated veins, scars or sinuses
Dravergonz’13
 No tapping marks
 No visible peristalsis
 Divarication of recti is present
 Hernial orifices- free
 External genitalia- normal
 Left Supraclavicular fossa- free
PALPATION:
 Not warm
 Non-tender
 Liver is not palpable
If liver is palpable, describe it as follows;
Liver is palpable







8 cm from the right costal margin
Tender/non-tender
Smooth surface
Firm in consistency
Lower border is sharp
Moves with respiration
Insinuation not possible
 Spleen is palpable
 6 cm from the left costal margin
 Tender
Dravergonz’13





Smooth surface
Moves with respiration
Spleenic notch is felt
Not ballotable and not bimanually palpable
Insinuation not possible
 Measurements:
Xiphisternum to Umbilicus
Umbilicus to pubic symphysis
Spino-umblical
RIGHT
distance
LEFT
Abdominal girth
22
12
15
15
98
 No fluid thrill
PERCUSSION:
 Liver span: 10 cm (Liver is shrunken)
 Spleen span: 8 cm (Spleen is enlarged)
 Shifting dullness is present
AUSCULTATION:
 Normal bowel sounds heard
 No hepatic or Spleenic bruit
 No venous hum
 No hepatic or Spleenic rub
Dravergonz’13
OTHER SYSTEM EXAMINATION:
RS:
 Normal vesicular breath sounds heard
 A stony dull note if felt on the right Infraaxillary, lower
Interscapular and infrascapular areas
CVS:
 S1, S2 heard
 No added sounds
 No murmur
CNS:




No focal neurological deficit
Flapping tremer is present
No constructional apraxia(able to draw star)
Reiter’s Number connection test- able to perform
(Record this in case sheet)
DIAGNOSIS:
It is a case of Ascites with cirrhosis of liver in
decompensated state with portal hypertension probably due to
alcoholic aetiology without hepatic encephalopathy.
Dravergonz’13
NOTES:
CNS:
 If a patient presents with INABILITY in using his limbs, it is
not necessary to elicit a detailed history regarding the motor
system.
 Don’t forget to mention about carotid pulsations
 The power of the muscles differs for each movement. Record it
carefully
 Power of a muscle for specific movement can be zero, but the
power of the whole limb can never be zero(in chronic cases).
 Look for the tone carefully
 If the reflexes are brisk, look for CLONUS.
RS:
 History of smoking, contact history, occupational history and
socioeconomic history are important.
 General examination, start with whether the patient is
comfortable or dyspnoeic at rest.
CVS:
 Don’t forget to look for JVP
 Measure BP in all the 4 limbs
 In other system examination, look for cripitations
ABDOMEN:
 Don’t forget to look for JVP
 History of alcohol intake should be in detail
 In other system examination, look for right sided pleural
effusion, flapping tremer, constructional apraxia.
Dravergonz’13
 For each case write the investigation and treatment
particular to that case only.
 Refer Mathew’s manual of medicine for investigation and
treatment
ALL THE BEST