portal hypertension History

Name
Age
Sex
Occupation
Residence
Marital status
Date of admission
C/o
Vomiting for 1 month

History of Present Illness

 Haematemesis :Onset .Times .Amount of each .Color : red or coffee ground vomits.Containing blood clots . Effect on the patient: loss his consciousness. Palpitation syncopated attack .send to the hospital on his feet or ambulatory. Received fluid .units of blood .endoscopy. bleeding stop spontaneously or by intervention

  Stool : colour (melaena- fresh blood), Amount containing blood clots .constipation or diarrhoea , when did it stopped  

Felling of a mass :Onset .site .initial size . How he notice the swelling .final size .associated with trauma.other masses associated pain

 left upper quadrent  pain : Onset .site .Duration . Severity .Character. Radiation .Relieving and Aggravating factors and Association

Symptoms of systemic effect of cirrhosis:

● Change in behavior mood or sleep pattern.

● Bleeding  tendency :Bleeding gum  during teeth brushing , easy bruisability .Haemtemsis .epistaxis

:Abdominal distension

 Jaundice

:Other GIT Symptoms

Easy satiety. Bloating , belching,Nausea and vomiting
Heart burn :  Onest , During day or night , relieving and aggravating factors 

Symptoms of Malignancy

Weight loss 

symptoms of anemia (Fatigability , SOB and palpitation on exertion ).

Symptoms of metastasis:  

● CVS + Respiratory:cough with haemoptysis chest pain lower limb edema.

● CNS:loss of consciousness . Headache . Convulsion .

● Genitourinary:urine amount colour and frequency

● Menstrual cycle: menorrhagea

Fill the gap

●  e.g seen in x Centre received management .done endoscopy and sclerotherapy or band ligation.

Past Medical History

● Hospitalization
● Surgical operation
● Endoscopy  or colonoscopy : When ,How many time, Diagnostic take biopsy . Had  sclerotherapy. Post procedure complications followup and diagnosis .
● Blood transfusion
● History of anemia.
● History of schistosmiasis
● History of peptic ulcer disease.

Family History 

- Similar condition
- Family history of other malignancies

Drug History 

Long term medication
Proton pump Inhibitors

Aspirin. NSAID
use Of b-blockers and duratics

Social History 

Home condition
Water and electricity
Level of education
Smoking
Alcohol abuser
Health insurance
Blood group
Nutritional Habits