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History Taking for Abdominal Distention
1. Patient Demographics
Name, age, sex, occupation, address, socioeconomic status
2. Chief Complaints
Abdominal distention: duration and progression
Any associated complaints (e.g., swelling of legs, jaundice, altered sensorium)
3. History of Presenting Illness
a) Details of Abdominal Distention
Onset: When did the abdominal distention start? Was it sudden or gradual?
Progression: Has it been increasing steadily or fluctuating?
Location: Is the distention generalized or more in a particular area?
Associated symptoms:
Pain or discomfort: Is there any pain? If yes, describe its character, location, and severity.
Early satiety: Feeling full quickly after eating.
Loss of appetite or weight loss: Any recent changes in appetite or weight.
Shortness of breath: Especially on lying down (may suggest massive ascites or pleural effusion)5.
Swelling of legs: Pedal edema.
Scrotal swelling: In males.
Nausea or vomiting.
Change in bowel habits: Constipation or diarrhea.
Urinary symptoms: Scanty urine output.
b) Symptoms Suggestive of CLD and Its Complications
Jaundice: Yellowish discoloration of eyes/skin.
Pruritus: Generalized itching.
Bleeding manifestations: Gum bleeding, epistaxis, melena, hematemesis.
Altered sensorium: Confusion, drowsiness, sleep disturbances (hepatic encephalopathy).
Fever: May suggest infection such as spontaneous bacterial peritonitis5.
History of abdominal hernia: Umbilical or inguinal swelling.
c) Precipitating or Aggravating Factors
Recent infection, GI bleeding, high protein intake, constipation, use of diuretics, or any new medication.
Review of Systems
Symptoms in other systems: respiratory (cough, breathlessness), cardiovascular (palpitations, chest pain), renal (urine output), neurological (confusion, drowsiness).
4. Past Medical History
Previous episodes of similar complaints.
Known diagnosis of liver disease, hepatitis, heart or kidney disease.
History of diabetes, hypertension, tuberculosis.
Previous abdominal surgeries or blood transfusions.
5. Family History
Family history of liver disease, GI malignancy, or inherited metabolic diseases.
6.Personal History
Alcohol intake: Type, quantity, duration, last intake.
Smoking or tobacco use.
IV drug use.
High-risk sexual behavior.
Dietary habits.
Drug History
Current medications (especially diuretics, lactulose, beta-blockers, hepatotoxic drugs).
Over-the-counter or herbal remedies.
Any drug allergies.
Menstrual and Obstetric History (if female)
Last menstrual period, cycle regularity, pregnancies, history of menorrhagia.
Socioeconomic History
Occupation and living conditions.
10. Summary and Clarification
Summarize the main findings to the patient and clarify any doubts.
Ask if there is anything else the patient would like to add.
Key Points:
Inquire specifically about features of decompensated CLD: ascites, jaundice, GI bleeding, hepatic encephalopathy, and pedal edema.
Ask about complications like spontaneous bacterial peritonitis (fever, abdominal pain), hernias, and hepatic hydrothorax (breathlessness).
Alcohol and viral hepatitis history are crucial in Indian settings.
Identifying Data:
Mr. Vijay Singh, a 52-year-old male, farmer by occupation, resident of rural Uttar Pradesh.
Abdominal distention for 8 months
Swelling of both legs for 4 months
Loss of appetite and weight loss for 4 months
History of Presenting Complaints
The patient, Mr. Vijay Singh, a 52-year-old male, was apparently well until about 8 months ago when he noticed a gradual increase in the size of his abdomen. The distention started insidiously and has progressed steadily. He reports a sense of fullness, tightness of clothes, and discomfort, especially when lying flat. There is no history of sudden or severe pain.
About 4 months ago, he developed swelling of both feet and lower legs, which is more pronounced in the evenings and reduces after rest. He also reports loss of appetite and unintentional weight loss during this period. He feels full quickly after eating small meals (early satiety).
He denies any history of fever, vomiting, hematemesis, melena, or jaundice. There is no history of pruritus, altered sensorium, or confusion. He has not noticed any change in urine color or bowel habits. There is no history of chest pain, palpitations, breathlessness, or cough. He has not had similar complaints in the past.
Past History
No history of diabetes, hypertension, or tuberculosis.
No previous hospitalizations or surgeries.
No blood transfusions in the past.
No known drug allergies.
Personal History
Alcohol: Consumes country liquor daily (approximately 180 ml/day) for 20 years, last intake 2 days ago.
Smoking: Smokes 5-6 bidis/day for 25 years.
Diet: Mixed; reports poor appetite in recent months.
Sleep: Disturbed due to abdominal discomfort.
Bowel and bladder habits: Normal.
No history of intravenous drug use or high-risk sexual behavior.
Family History
No family history of liver disease, tuberculosis, or malignancy.
No similar complaints in other family members.
Socioeconomic History
Occupation: Farmer.
Lives in a rural area with wife and two children.
Lower-middle socioeconomic status.
Limited access to healthcare facilities.
This format follows the standard clinical history-taking structure and is tailored for a case of abdominal distention in chronic liver disease, as expected in Indian medical examinations
1. What are the common causes of abdominal distention in a patient with chronic liver disease?
Answer:
The most common cause is ascites due to portal hypertension. Other causes include hepatomegaly, splenomegaly, intestinal gas, and rarely, tumors or cysts24.
2. What is ascites and why does it develop in CLD?
Answer:
Ascites is the accumulation of free fluid in the peritoneal cavity. In CLD, it develops mainly due to portal hypertension (increased hydrostatic pressure in portal circulation), hypoalbuminemia (reduced oncotic pressure), and renal sodium and water retention4.
3. What symptoms are associated with ascites?
Answer:
Symptoms include abdominal distention, weight gain, abdominal discomfort or pain, early satiety, difficulty breathing (if massive), and swelling of ankles46.
4. What are the complications of ascites in CLD?
Answer:
Complications include:
Spontaneous bacterial peritonitis (SBP): Infection of ascitic fluid, presenting with abdominal pain, fever, and tenderness.
Hernias: Especially umbilical and inguinal hernias due to increased intra-abdominal pressure.
Hepatic hydrothorax: Fluid accumulation in the pleural cavity, usually right-sided.
Renal dysfunction: Such as hepatorenal syndrome4.
5. How do you confirm the presence of ascites?
Answer:
Ascites is suspected clinically by abdominal distention, shifting dullness, and fluid thrill. It is confirmed by imaging (ultrasound abdomen) and diagnostic paracentesis (analysis of ascitic fluid)24.
6. What are the causes of ascites other than cirrhosis?
Answer:
Other causes include heart failure, nephrotic syndrome, malignancy, tuberculosis, and pancreatitis4.
7. How is ascites managed in CLD?
Answer:
Salt restriction (less than 2 grams/day)
Diuretics (spironolactone, furosemide)
Therapeutic paracentesis for tense or refractory ascites
Treat underlying cause and complications
TIPS (Transjugular Intrahepatic Portosystemic Shunt) in refractory cases4.
8. What is spontaneous bacterial peritonitis (SBP) and how is it diagnosed?
Answer:
SBP is infection of ascitic fluid without an obvious source. It presents with abdominal pain, fever, and altered mental status. Diagnosis is by ascitic fluid analysis showing neutrophil count >250 cells/mm³ and positive culture4.
9. What are the risk factors for developing ascites in CLD?
Answer:
Advanced liver disease, ongoing alcohol use, hepatitis B/C infection, poor nutrition, and high portal pressure are major risk factors46.
10. Why does pedal edema occur in CLD with ascites?
Answer:
Pedal edema occurs due to hypoalbuminemia (reduced plasma oncotic pressure), increased hydrostatic pressure from portal hypertension, and secondary hyperaldosteronism leading to sodium and water retention4.