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Detailed Case History and Examination: Chronic Liver Disease with Increased Ascites

I. Patient Profile:

  • Name: Mr. Rakesh Sharma

  • Age: 55 years

  • Gender: Male

  • Education: Graduate (B.Com)

  • Occupation: Retired Bank Manager

  • Date of Admission: July 8, 2025

  • Date of Examination: July 11, 2025

  • Informant: Patient himself

  • Reliability of Information: Reliable

II. Chief Complaints (C/C):

  1. Generalized weakness and easy fatigability for 2 months

  2. Increased abdominal distention for 1 month

  3. Swelling of both feet for 1 month

  4. Occasional yellowish discoloration of eyes for 3 weeks

  5. Decreased urine output for 2 weeks

III. History of Present Illness (HPI):

Mr. Rakesh Sharma, a 55-year-old male, was reportedly stable on his prescribed medications until about 2 months prior to presentation. At that time, he began experiencing increasing generalized weakness and easy fatigability. This symptom has been progressively worsening, significantly impacting his daily activities and causing exhaustion even after minimal exertion. He denies any associated muscle cramps or numbness.

Approximately 1 month ago, he noted a significant and rapid increase in his abdominal distention, which has since become generalized and is associated with a feeling of fullness and discomfort. There is no associated abdominal pain, vomiting, or fever. He denies any recent history of diarrhea or constipation. Concurrently, he also developed swelling of both feet, which is pitting in nature, insidious in onset, and gradually progressive. The pedal edema is typically worse towards the evening and partially relieved by rest and leg elevation.

Over the last 2 weeks, he has observed a slight decrease in his urine output. The urine color remains normal, and he denies any dysuria or hematuria.

For the last 3 weeks, he has intermittently noticed yellowish discoloration of his eyes. This icterus is not constant and is not associated with itching, dark urine, or pale stools. He denies any history of bleeding from any site, including hematemesis, melena, epistaxis, or gum bleeding. There is no history of altered sensorium, disorientation, or abnormal sleep-wake cycles. He specifically denies any history of abdominal lump or dysphagia.

IV. Past History:

  • Chronic Liver Disease (CLD): Diagnosed 6 months ago with Chronic Liver Disease and ascites. At the time of diagnosis, he presented with mild abdominal distention. He was subsequently initiated on regular diuretic therapy (Furosemide and Spironolactone) and advised dietary modifications, which he reportedly adhered to.

  • Similar history in the past: Yes, initial presentation of abdominal distention and ascites 6 months prior to the current exacerbation.

  • History of Jaundice: Intermittent yellowish discoloration of eyes over the past 3 weeks, as mentioned in HPI. No significant history of severe jaundice episodes prior to this.

  • History of Blood Transfusion: Denied.

  • History of any drug intake: Regular intake of diuretics (Furosemide, Spironolactone) for 6 months. No history of hepatotoxic drug intake.

  • History of TB/DM/HTN/Bronchial Asthma/Epilepsy: Denied.

V. Family History:

  • Similar history in family or in surroundings: No family history of liver disease or other chronic illnesses.

Family history of TB/HTN/DM/Bronchial Asthma: Denied.

VI. Personal History:

  • Diet: Mixed diet, but reduced appetite for the past 2 months. No specific food allergies.

  • History of Loss of weight and Loss of Appetite: Significant loss of appetite for 2 months, leading to generalized weakness. Weight loss is difficult to assess accurately due to increasing ascites and edema.

  • Bowel and Bladder habits: Bowel habits are regular. Bladder habits: decreased urine output noted, no dysuria.

  • Sleep Disturbances: No significant sleep disturbances or altered sleep-wake rhythm reported.

  • Habits:

    • Smoking: Denied.

    • Alcohol: History of chronic alcohol consumption (approx. 60-80g/day) for 20 years, stopped 6 months ago upon diagnosis of CLD.

  • History of any exposure and travel to Endemic areas: Denied.

Drug History:

  • Allergy to any drugs: Denied.

  • Currently on Furosemide and Spironolactone.

General Examination:

  • Conscious/Oriented/Cooperative: Conscious, oriented to time, place, and person, cooperative.

  • Built/Nourishment: Moderately built, poorly nourished (muscle wasting noted, difficult to assess overall nourishment due to edema/ascites). Skin fold thickness reduced.

  • Pallor: Present (conjunctival and nail beds).

  • Icterus: Present (scleral icterus, mild).

  • Cyanosis: Absent.

  • Clubbing: Present (Grade I, pan clubbing).

  • Edema: Bilateral pitting pedal edema up to mid-shin (Grade ++). Sacral edema present.

  • Lymphadenopathy: Absent.

Signs of Liver Failure/Chronic Liver Disease:

  • Alopecia: Present (diffuse thinning of hair).

  • Icterus: Present (as above).

  • Parotid Gland Enlargement: Absent.

  • Spider Naevi: Present (multiple, >5, on chest and upper arms).

  • Gynaecomastia: Present (bilateral, mild).

  • Ascites: Present (gross, tense).

  • Testicular Atrophy: Present (mild).

  • Palmar Erythema: Present (diffuse).

  • White Nails (Leuconychia): Present.

  • Flapping Tremors (Asterixis): Absent.

  • Dupuytren's Contracture: Absent.

External Markers of HIV Infection: Absent.

Vital Signs:

  • Pulse: 88 beats/min, regular, normal volume, normal character, all peripheral pulses palpable.

  • BP: 100/60 mmHg (right arm, supine).

  • Respiratory Rate: 20 breaths/min, abdomino-thoracic, regular.

  • Temperature: 98.6°F (afebrile).

  • JVP: Elevated, 8 cm above sternal angle (measured at 45° inclination). No prominent 'a' or 'v' waves. Hepatojugular reflux positive (sustained elevation >3cm).

  • Fundus Examination: KF Ring (Kayser-Fleischer ring) absent.

Abdominal Examination:

Oral Cavity:

  • Hygiene: Fair.

  • Teeth: No caries, no dentures.

  • Tongue: Normal size, coated surface, pale color. No deviation, no tremors.

  • Palate/Tonsils/Breath Smell/Oropharynx: Palate and tonsils normal. Breath has a faint mousy (fetor hepaticus) smell. Oropharynx clear.

INSPECTION:

  • Shape: Grossly distended uniformly.

  • Flanks: Full.

  • All quadrants: Move equally with respiration (though restricted due to distension).

  • Umbilicus: Everted, central, no discoloration.

  • Skin: Stretched, shiny, presence of abdominal striae (striae gravidarum type). No sinuses, nodules, or localized bulging/retraction.

  • Movement of abdominal wall with respiration: Reduced but present.

  • Visible masses: Absent.

  • Visible dilated veins: Present (prominent periumbilical veins, flow away from umbilicus suggestive of portal hypertension; no definite caput medusae).

  • Visible Gastric/Intestinal Peristalsis: Absent.

  • Visible Pulsations: Absent.

  • Visible Scars/Pigmentation: Old, faded striae. No significant pigmentation.

  • External Genitalia: Normal male genitalia, mild testicular atrophy noted on general examination.

  • Hernial Orifices: No obvious swelling or impulse on coughing at inguinal or femoral orifices.

PALPATION:

  • Local Rise of Temperature: Absent.

  • Tenderness: No generalized or localized tenderness.

  • Guarding/Rigidity: Absent.

  • Rebound Tenderness: Absent.

  • Superficial palpation: No Sister Joseph nodule. Abdomen tense, difficult to palpate deeply. Dipping palpation used.

Palpation for Organs (using dipping palpation due to ascites):

  • Liver: Palpable 4 cm below the right costal margin in the right mid-clavicular line. Edge feels sharp, surface appears nodular, consistency is firm. Non-tender. Moves with respiration. Liver span (percussion) 14 cm. No pulsatility.

  • Spleen: Palpable 3 cm below the left costal margin in the left mid-clavicular line. Edge feels notched, surface smooth, consistency firm. Non-tender. Moves with respiration. Inability to insinuate fingers between mass and margins.

  • Kidney: Both kidneys not palpable.

  • Gall Bladder: Not palpable.

  • Urinary Bladder: Not palpable.

  • Aorta and common femoral vessels: Aorta not readily palpable due to distension. Femoral pulses palpable, normal volume and character.

  • Palpable mass: No other palpable masses.

Abdominal Girth: 105 cm (measured at the level of the umbilicus).

PERCUSSION:

  • Liver Dullness: Upper border at 5th right intercostal space in mid-clavicular line. Lower border at 4 cm below right costal margin in mid-clavicular line. Liver span 14 cm.

  • Spleen: Traube’s space is dull. Castell's method: dull on full inspiration. Nixon's method: dullness >8 cm.

  • Ascites:

    • Shifting Dullness: Positive. Flank dullness present, shifts to the dependent side when the patient is turned.

    • Fluid Thrill: Positive.

    • Puddle Sign: Not specifically elicited (shifting dullness already positive indicating significant fluid).

  • Renal Angle Percussion: Resonant bilaterally.

AUSCULTATION:

  • Bowel sounds: Sluggish (2-3/min), low pitched.

  • Venous Hum: Present (continuous hum heard between umbilicus and right hypochondrium, suggestive of patent umbilical vein in portal hypertension).

  • Arterial Bruits: No aortic, renal, or splenic bruits.

  • Liver Bruit: Absent.

  • Friction Rub/Succussion Splash: Absent.

  • Uterine Souffle: Not applicable.

Per Rectal Examination / Per Vaginal Examination (Females):

  • Per Rectal Examination: (Done with consent) No perianal abnormalities. Anal sphincter tone normal. No rectal mass. No mass in Pouch of Douglas. Finger withdrawn, no blood, pus, or mucus.

Examination of Other Systems:

  • CVS: Apex Beat in 5th left intercostal space, just medial to mid-clavicular line, normal character. S1 S2 heard in all areas, no murmurs. No added sounds.

  • RS: Normal Vesicular Breath Sounds bilaterally. No adventitious sounds (rhonchi, crepitations, pleural rub). Chest expansion symmetrical but reduced due to ascites.

  • CNS: No flapping tremors. Sensorium is clear, no altered sensorium. All reflexes (deep tendon reflexes, superficial reflexes) are normal. No focal neurological deficits.

Diagnosis:

Chronic Decompensated Liver Disease, likely Alcoholic Cirrhosis, with Portal Hypertension and now presenting with increased Ascites (Grade III), Hepatosplenomegaly, and evidence of Hepatic Decompensation (Icterus, Edema, Palmar Erythema, Spider Naevi, Gynaecomastia, Testicular Atrophy, Leuconychia).

  • Ascites for evaluation (likely due to progression of CLD/decompensation).

  • No overt Hepatic Encephalopathy at present.

  • No evidence of active GI bleed.