Abdomen 1

Abdomen 1

4 Personal history

Ashraf Mohamed Ali, male patient,35 years old, he was born and low lives in Zagazig, he is married and has 2 off-springs, he works as a tailor, he is moderate cigarette smoker with no other special habits of medical importance.

There is history of contact  to water canals with no history of traveling abroad .

4 c/o

Pain in left & right upper quadrants of the abdomen one week duration.

4 HPI

The condition started 10 years ago by gradual onset and progressive course of dull  aching localized pain in the left upper quadrant of abdomen, not related to position, respiration, exercise or meals. one year later, the patient developed dull  aching localized pain in the right upper quadrant of abdomen, not related to position, respiration, exercise or meals. The patient saught medical advice, investigated by urine, stool analysis and abdominal ultrasonography and treated by silymarin and anti bilharzial treatment

The patient remained symptom free till one week ago when he re-experienced  dull  aching localized pain in the left & right  upper quadrants of abdomen, not related to position, respiration, exercise or meals.

No history of abdominal swellings, abdominal distension, upper or lower GIT symptoms, hepatobiliary or urogenital symptoms, no constitutional symptoms and no L.L oedema.

No symptoms of other system affection

4 Past history

-          There is past history of Bilharziasis Since he was 9 years old, manifested by dysentery and terminal hematuria, investigated by urine and stool analysis, treated by distocid tablets.

-          No past history of blood transfusion, or past history suggesting previous attacks of acute hepatitis   

-          No DM no HTN.

-          No past history of operations or drugs. 

4 Family history

-          No consanguinity.

-          No common diseases.

-          No similar condition.

4 General exam

4 Overview

-          Temperature : 37

-          Blood pressure 110/70

-          Pulse : regular pulse, 75 /minute, average volume, no special characters, vessel wall is not felt, equal on both sides with intact peripheral pulsations.

-          The patient is fully conscious, well oriented for time place and persons, average mood and memory, the patient is co-operative with average intelligence, the patient looks well average. built, No jaundice, pallor or cyanosis.

4 H&N

-          No parotid enlargement, no fine silky hair, no fetor hepaticus, no wasting of muscles, the skin shows no spider naevi or paper money appearance.

-          Neck veins are congested not pulsating.

4 Extremities

-          No oedema L.L.

-          No clubbing, no leuchonychia, no capillary pulsations and no flappy tremors.

-          The skin shows no spider naevi, no palmer erythema, no paper money appearance, no S.C haemorrhage. no wasting of muscles .  

4 Local exam :

4 Inspection__

The abdomen moves freely with respiration, normal abdominal contour, there is localized oval shaped swelling in the left hypochondrium and left lumber regions which decreased in size on doing rising up test, no dilated veins, regarding the skin: there is no scars, no stria no scratch marks, no  sc haemorrhage, no pigmentation, no oedema in anterior abdominal wall with normal skin elasticity, no abdominal or inguinal hernias and no gynecomastia .there is wide subcostal angle confirmed by thumb test, mild epigastric pulsation, no visible peristalsis. There is mild divarication of recti. Regarding the umbilicus, it is shifted downwards flat and transverse in shape no hernia no discharge. The skin shows no dilated veins no nodules no scars, pigmentation or ulcers, there is male distribution of suprapubic hair with normal genitalia, regarding the back no deformity, no swelling, no scars.

4 Palpation__

By superficial palpation:

Apart from oval shaped swelling in the left hypochondrium and left lumber regions, no other swellings, no rigidity, no tenderness, no hyperesthesia.

By deep  palpation

-          The liver is firm in consistency ,sharp border ,the right lobe is felt 3 fingers below the right costal margin in the right midclavicular line while the left lobe is felt hand breadth below xiphisternum in the midline with smooth surface. It is neither tender nor pulsating (to be differentiated from other masses in the right hypochondrium)

-          The spleen is firm in consistency, rounded notched border, it is felt 7 fingers below the left costal margin (or it is huge in size) with smooth surface, it is not tender or pitted (to be differentiated from other masses in the left hypochondrium and left lumber specially left kidney).

          Otherwise, there is  no other palpable abdominal organs.   

4 Percussion__

-          Upper border of liver is in the 6^th intercostals space in the right midclavicular line  detected by heavy percussion with the hepatic san =16 cm.

-          There is dullness below the right costal margin and xiphisternum detected by light percussion and continuous  with the hepatic dullness.

-          There is dullness at the level of the umbilicus detected by light percussion and continuous with traub's area dullness.

-          No ascites detected by percussion .

    

4 Auscultation__

There is audible intestinal sound, no vascular sounds no hepatic or splenic rubs no sucussion splash, no ascites detected by puddle's sign. the liver is detected below the right costal margin by scratch test .   

4 Investigation

-          Urine and stool analysis for viable bilharzial ova.

-          Blood for CBC(anemia), LFT, serological tests of bilharziasis, hepatitis markers.

-          ECG for bilharzial cor pulmonale.

-          Barium studies for …….

-          Ultrasonography  for ………

-          Endoscopies upper and lower for ………….

4 Treatment

-          Stop any hepatotoxic drugs

-          Silymarin

-          B-blockers (inderal) to decrease the portal pressure specially if there is varices deteced by endoscopy (silent varices as no bleeding in the pateint's story)

-          Spleen can be excised if it is accused in blood cells destruction (hypersplenism)

4 Diagnosis :

A case of hepatosplenomegaly for D.D most probably bilharzial, there is no signs of LCF and no previous attacks of bleeding with no complications

Or A case of hepatosplenomegaly for D.D most probably bilharzial, there is vascular decompensation but no cellular decompensation with no complications .

 

NB

·         Hepatosplenomegaly  from local exam and sonar.

·         Bilharzial from history, urine and stool analysis and serological tests for bilharzia (rectal snip is much better).

·         No cellular decompensation from absence of symptoms and signs of LCF and LFTs.

·         vascular decompensation from signs of portal hypertension (splenomegaly,portal venography and manometry are much better).

·         Not  Complicated as there is no evidence of spontaneous bacterial peritonitis, malignancy or hypersplensim (see how to detect each one in B.H theoretical notes).