Fig. 5D.62: Reitan’s number-connection test.

Types of hepatorenal syndromes (HRS)

Type 1 hepatorenal syndrome Type 2 hepatorenal syndrome

It is characterized by progressive oliguria, a rapid

rise of the serum creatinine to above 2.5 mg/dL

and has a very poor prognosis

Usually precipitated by spontaneous bacterial

peritonitis Without treatment, median survival is less than 1 month and almost all patients die within 10 weeks

after the onset of renal failure

It is characterized by a reduction in glomerular filtration, moderate and

stable increase in serum creatinine (>1.5 mg/dL), but it is fairly stable

and has a better prognosis than Type 1 HRS

Usually occurs in patients with refractory ascites (resistant to diuretics)

Median survival is 3–6 months

Precipitating factors for hepatorenal syndrome

Gastrointestinal bleeding

Aggressive paracentesis

Diuretic therapy

Sepsis including spontaneous bacterial peritonitis

Diarrhea

SITES OF PORTOSYSTEMIC ANASTOMOSIS (FIG. 5D.63)

Fig. 5D.63: Sites of portosystemic anastomosis in cirrhosis.

CLASSIFICATION OF PORTAL HYPERTENSION (FIG. 5D.64)

Fig. 5D.64: Classification of portal hypertension according to site of vascular obstruction.

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A. CASE SHEET FORMAT

HISTORY TAKING

Name:

Age:

Sex:

Residence:

Occupation:

Chief complaints:

________ × days

________ × days

________ × days

History of presenting illness:

HIGHER MENTAL FUNCTION

Altered state of consciousness:

Onset

Any seizures and blackouts

Any fall/injuries

Any ear or nose bleed

Fever

Any ear pain or discharge

Drug history

Any addictions.

Mental state and cognition:

Changes in the memory

State of alertness and drowsiness

Changes in the mood and affect (loss of spontaneity)

Language changes

Loss of spatial orientation

Diminished ability to carry out routine activities of daily living.

Other higher mental functions:

Speech difficulty

Difficulty to recognize people or objects

Inappropriate crying or laughter

Lack of interest

Social disinhibition

Delusions/hallucinations.

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CRANIAL NERVE DYSFUNCTION

Ask about:

Loss of vision, smell, and taste

Alteration in facial feeling

Double vision/visual symptoms

Problems with swallowing and chewing

Speech alterations

Vertigo/hearing abnormalities

Hoarseness of voice, dysphagia, nasal regurgitation, and nasal intonation of speech

Pain/difficulty in neck movements.

Example

Left lower motor neuron (LMN) 7th nerve palsy: History of retroauricular pain followed by abrupt

onset deviation of angle of mouth to right with slurring of speech and difficulty in left eye closure

with history of hyperacusis.

MOTOR DYSFUNCTION

Weakness

Distribution of weakness:

Is it symmetrical/asymmetric:

Paresis or plegia:

Limbs involved:

Ipsilateral or contralateral:

Patterned weakness.

Example

Right middle cerebral artery (MCA) territory embolic infarct: History of sudden onset, complete loss

of power in left upper limb and lower limb. Weakness maximum at onset and nonprogressive.

Onset and progression:

Acute, subacute, or chronic

Progression of the weakness:

Ascending weakness or descending weakness

Ellsberg phenomenon

Variation throughout the day

Muscles/limb(s) involved.

Proximal upper limb—

shoulder/arm:

Difficulties in combing hair, reaching for high objects, winging of scapula

Distal upper limb—forearm/hand: Finger/wrist drop, poor hand grip, cannot open jar, difficulty in

buttoning/unbuttoning

Proximal lower limb—pelvic/thigh: Cannot rise from chair or squatting position, waddling gait

Distal upper limbs—leg/foot: Difficulty in gripping chappals, cannot walk on heels/toes foot drop

Neck muscles Dropped head/broken neck

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Trunk Inability to roll on the bed

Example

Guillain–Barré syndrome (GBS): History of preceding gastrointestinal (GI) infection followed by

acute onset difficulty in getting up from squatting position, difficulty walking, progressing to involve

upper limbs (difficulty combing hair), and neck muscle weakness. No sensory symptoms.

Wasting/Loss of Muscle Bulk

Wasting—present/absent

Fasciculations—present/absent

Stiffness of Limbs

Stiffness—present/absent

Heaviness—present/absent

Gait Abnormalities

Limp or dragging foot

Scissoring/circumduction.

Involuntary Movements

Type

Symmetrical/asymmetrical

Part of the body involved

Present at rest

Functional disability.

SENSORY DYSFUNCTION

Numbness/loss of feeling

Altered feeling:

Paresthesia

Dysesthesias (tingling and pin-needles)

Spontaneous pain

Pattern of sensory loss.

CEREBELLAR HISTORY

Swaying to one side

Tremors while reaching objects

Lack of coordination of activities

Overshooting acts

Abnormal involuntary eye movements (oscillopsia/nystagmus).

HISTORY SUGGESTING MENINGITIS/RAISED INTRACRANIAL

PRESSURE

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Headache

Neck pain

Projectile vomiting

Blurring of vision

Seizures

Photophobia.

HISTORY SUGGESTING AUTONOMIC DYSFUNCTION

Dryness of skin

Palpitations

Perspiration

Syncopal attacks/postural giddiness

Bladder dysfunction:

Urinary retention

Loss of awareness of bladder control

Frequency, urgency

Urge/overflow incontenence.

REVIEW OF COMMON NEUROLOGICAL SYMPTOMS

Headaches

Onset and duration of headache

Location of headache, unilateral versus bilateral

Severity

Frequency

Radiation

Quality of headache (dull and diffuse)

Types:

Continuous

Pulsating

Stabbing

Sharp

Throbbing

Dull

Thunderclap

Alleviating factors

Triggers for the headache/aggravating factors

Temporal association (headache not worse in mornings)

Association with nausea/vomiting/tearing of eyes/redness of eyes

Vision changes before or during headache

Precipitating factors:

Stress

Menses

Allergens

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Sleep deprivation

Coughing

Straining

Bending forwards

Associated motor/sensory symptoms: Weakness, numbness, and tingling in upper or lower

extremities

Photophobia/phonophobia

Systemic symptoms—weight loss, low energy, and anorexia

Fever and neck stiffness

History of head trauma

History of migraine

Family history of migraines

Effect on daily activities

Use of oral contraceptive pills

Caffeine intake

Smoking and alcohol history.

Example

Classical migraine: Visual aura followed by insidious onset, unilateral, severe pulsating type of

heading lasting for >4 hours associated with nausea and photophobia. Repeated such attacks

every month with history of some identifiable precipitating factors and a positive family history of

migraine.

Seizures

Onset and duration

Frequency

Factors which precipitate these episodes

Injury sustained as a result of the seizure

Postictal symptoms: Confusion

Associated sensory deficits

Associated motor deficits

Associated cognitive deficits

Muscle spasms

Anatomical progression of motor involvement (e.g. Jacksonian March)

Symptoms suggesting aura

Associated incontinence

Tongue biting and salivation

Automatisms associated with these episodes

History of head trauma

Perinatal infection

Drug history

History of seizure disorder

Family history of seizure disorders

Effect on daily activities.

Example

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Generalized tonic clonic seizure (GTCS): Abrupt onset tonic clonic contraction of muscle associated

with tongue bite and urinary incontinence. Patients generally regain consciousness within few

minutes with postictal confusion and headache.

Past history:

Asthma

Chronic obstructive airway disease

Tuberculosis

History of contact with tuberculosis

Diabetes mellitus (DM)

Hypertension (HTN)

Ischemic heart disease (IHD)

Seizure disorder and drugs used (in detail).

Family history:

(draw pedigree chart representing three generations)

Personal history:

Bowel habits

Bladder habits

Appetite

Loss of weight

Occupational exposure

Sleep

Dietary habits and taboo

Food allergies

Smoking (in smoking Index or Pack years)

Alcohol history (__ grams of alcohol/day or ___ units of alcohol/week).

Menstrual and obstetric history:

G__P__L__A__

Age of menarche __

Menopause at __

Flow—amenorrhea/oligorrhea/menorrhagia.

Summarize:

Differential diagnosis:

GENERAL EXAMINATION

Patient

Conscious

Cooperative

Obeying commands

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Wt (kg)/Ht2

(meters)

Grading according to WHO for Southeast Asian countries

Vitals

Pulse

Rate

Rhythm

Volume

Character

Vessel wall thickening

Radio-radial delay and radio-femoral delay

Peripheral pulses

Carotid and vertebral bruit

Blood pressure

Right arm

Left arm

Leg—right/left

Respiratory rate

Regular

Abdominothoracic (male) or thoracoabdominal (female)

Usage of accessory muscles

Jugular venous pulse

Waveform

Jugular venous pressure

__ cm of blood above sternal angle (+ 5 cm water)

On Physical Examination

Pallor

Icterus

Cyanosis

Clubbing

Lymphadenopathy

Edema

Others Head to Toe

Nerve thickening

Neurocutaneous markers

External markers of atherosclerosis

Signs of nutritional deficiency, alcoholism, etc.

Any other general examination finding

NERVOUS SYSTEM EXAMINATION

Right/left handed person

Education

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