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Decompensated Features of Chronic Liver Disease (CLD)

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Definition of Decompensation

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Clinical Staging (Baveno Classification)

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Cardinal Features of Decompensation

1. Ascites (Most Common - 80%)

• Most frequent sign of decompensation; occurs at 7-10% per year in compensated cirrhosis
• Caused by portal hypertension + splanchnic vasodilation + sodium/water retention
• Clinical signs: increased abdominal girth, bulging flanks, flank dullness, shifting dullness
• Hyponatremia (serum Na <130 mEq/L) is present in ~25% of patients with cirrhosis and ascites - a marker of disease severity
• Complications: Spontaneous Bacterial Peritonitis (SBP) - infection without an obvious surgical source; Refractory ascites - unresponsive to diuretics, requires repeated paracentesis or TIPS

2. Variceal Hemorrhage

• Gastroesophageal varices present in ~50% of newly diagnosed cirrhosis
• Prevalence ranges from 40% (Child A) to 85% (Child C)
• Small varices bleed at ~5%/year; large varices bleed at ~15%/year
• Predictors: large variceal size, severe liver disease, red wale markings
• Presents as hematemesis, melena, or both
• Gastric varices (especially fundal) carry higher bleeding risk than esophageal

3. Hepatic Encephalopathy (HE)

• Brain dysfunction caused by liver insufficiency and/or portosystemic shunting
• Pathogenesis: Ammonia accumulates (due to portosystemic collaterals + decreased hepatic metabolism) → damages astrocytes (Alzheimer type II astrocytosis) → GABA-mediated cortical depression
• Also: manganese deposition in globus pallidus → impaired motor function
• Grades I-IV: from subtle personality changes/sleep disturbance → confusion → stupor → coma
• Precipitants: GI bleed, infection, constipation, sedatives, electrolyte imbalance, dehydration

4. Jaundice

• Results from inability to excrete bilirubin (liver insufficiency)
• In cholestatic disease (PBC, PSC), may reflect biliary damage rather than pure liver failure
• Accompanied by coagulopathy (prolonged INR) and hypoalbuminaemia

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Secondary/Progressive Decompensation Features

5. Hepatorenal Syndrome (HRS)

• Functional renal failure in setting of advanced cirrhosis; no intrinsic kidney pathology
• Results from extreme splanchnic vasodilation → renal vasoconstriction → decreased GFR
• HRS Type 1 (AKI type): Rapid deterioration (creatinine doubles to >2.5 mg/dL within 2 weeks); very poor prognosis
• HRS Type 2: Slower, associated with refractory ascites

6. Spontaneous Bacterial Peritonitis (SBP)

• Infection of ascitic fluid without a surgical cause
• Diagnosis: ascitic fluid PMN count >250 cells/mm³
• Common organisms: E. coli, Klebsiella, Streptococcus
• Associated with 30-50% in-hospital mortality if untreated

7. Cardiopulmonary Complications

• Cirrhotic cardiomyopathy: High-output heart failure with decreased peripheral O₂ utilization
• Hepatopulmonary syndrome (HPS): Pulmonary capillary dilation → right-to-left shunt → hypoxemia (PaO₂ <80 mmHg, or increased A-a gradient)
• Portopulmonary hypertension (PoPH): Vasoconstrictive substances bypass hepatic metabolism → irreversible pulmonary HTN

8. Coagulopathy

• Decreased synthesis of clotting factors (II, V, VII, IX, X)
• Thrombocytopenia (from hypersplenism + decreased thrombopoietin)
• Results in prolonged PT/INR; bleeding tendency

9. Other Advanced Features

• Hepatocellular carcinoma (HCC): Can develop at any stage and precipitate/accelerate decompensation
• Acute-on-Chronic Liver Failure (ACLF): A distinct syndrome - acute deterioration on a background of cirrhosis, with organ failures; high short-term mortality
• Infection/Sepsis: Now recognized as a distinct stage in the natural history; poor survival even after infection clearance
• Muscle wasting/Sarcopenia and malnutrition: Progressive loss of muscle mass
• Hepatic hydrothorax: Transudative pleural effusion (usually right-sided) from ascitic fluid passing through diaphragmatic defects

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Physical Signs of Decompensation

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Prognostic Scoring

• Child-Turcotte-Pugh (CTP): Scores ascites, encephalopathy, bilirubin, albumin, INR (range 5-15). Child A (5-6) = good; Child C (10-15) = poor
• MELD/MELD-Na score: Incorporates creatinine, bilirubin, INR, and sodium - used for liver transplant prioritization

Median survival in compensated cirrhosis: 9-12 years. Median survival in decompensated cirrhosis: ~1.6-2 years. - Goldman-Cecil Medicine, Sleisenger & Fordtran's GI and Liver Disease

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Liver Span - Normal Range and Abnormal Values

How to Measure Liver Span

• Upper border: Use heavy percussion from the mid-thorax downward in the MCL - the point where lung resonance changes to hepatic dullness marks the upper liver border (normally at the level of the right nipple, ~5th intercostal space)
• Lower border: Use light percussion (examiner's ear close to the abdomen) from the right lower quadrant upward - the point where tympany changes to dullness marks the lower border (normally at the right costal margin)
• Can also be percussed at the midsternal line and anterior axillary line
• Palpation of the lower border below the costal margin alone is unreliable for determining span - percussion is superior

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Normal Liver Span by Percussion

Adult Values (Mid-Clavicular Line)

• Goldman-Cecil Medicine states: normal liver span in the MCL is 6 to 12 cm; a span <12 cm reduces the likelihood of hepatomegaly
• Clinical Methods (NCBI): mean percussion span is 7 cm (women) and 10.5 cm (men)

Average Liver Span by Percussion Line (Adults)

By Sex (Clinical vs Ultrasound - Research Data)

Note: Ultrasound consistently gives larger values than clinical percussion (statistically significant, p<0.001), because percussion underestimates the true hepatic extent.

Paediatric Values (by percussion, MCL - Johns Hopkins study)

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Abnormal Values

Hepatomegaly (Enlarged Liver)

• Vascular/Congestive: Right heart failure, Budd-Chiari syndrome, cardiac cirrhosis
• Metabolic/Infiltrative: Non-alcoholic fatty liver disease (NAFLD), haemochromatosis, Wilson's disease, amyloidosis, glycogen storage disorders
• Infective/Inflammatory: Viral hepatitis (acute), hepatic abscess, schistosomiasis, malaria, infectious mononucleosis
• Neoplastic: Primary HCC, metastatic carcinoma (most common cause of massive hepatomegaly), lymphoma, haemangioma
• Cholestatic: Primary biliary cholangitis, primary sclerosing cholangitis
• Haematological: Sickle cell disease, thalassaemia, polycythaemia vera

• Smooth + tender = acute viral/alcoholic hepatitis, hepatic congestion (CCF)
• Hard + irregular = cirrhosis, malignancy
• Smooth + non-tender = early cirrhosis, fatty liver, infiltrative disease

Shrunken/Small Liver

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Important Caveats

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Clinical Pearl

"A liver edge felt up to 2 cm below the right costal margin is considered normal, but a normal-sized liver can be displaced downward by other abnormalities such as emphysema."

• Goldman-Cecil Medicine

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GI Examination — MBBS Final Year Practical

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1. GENERAL EXAMINATION (Before touching the abdomen)

• Built, nourishment, BMI
• Pallor (anaemia — GI bleed, malabsorption)
• Icterus / Jaundice
• Cyanosis
• Clubbing (IBD, cirrhosis, malabsorption)
• Koilonychia (iron deficiency), Leuconychia (hypoalbuminaemia)
• Lymphadenopathy — especially left supraclavicular (Virchow's node) = gastric ca
• Oedema (pedal — hypoalbuminaemia, portal HTN)
• Parotid enlargement (alcoholic liver disease)
• Fetor hepaticus
• Flapping tremor / Asterixis (hepatic encephalopathy)
• Gynaecomastia, testicular atrophy (CLD)
• Loss of axillary/pubic hair (CLD)

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2. HANDS & UPPER LIMBS

• Palmar erythema (CLD, pregnancy)
• Dupuytren's contracture (alcoholic liver disease)
• Leuconychia (hypoalbuminaemia)
• Koilonychia (iron deficiency)
• Clubbing
• Asterixis (flapping tremor) — ask patient to dorsiflex wrists
• Spider naevi on arms/chest (CLD) — >5 above the nipple line is significant
• Muscle wasting

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3. FACE & NECK

• Scleral icterus (jaundice)
• Conjunctival pallor
• Kayser-Fleischer rings (Wilson's disease — slit lamp needed)
• Angular stomatitis, glossitis (nutritional deficiency)
• Parotid enlargement
• Fetor hepaticus
• Virchow's node — left supraclavicular fossa
• JVP — raised in right heart failure causing congestive hepatomegaly

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4. CHEST WALL (relevant)

• Spider naevi — >5 significant (CLD)
• Gynaecomastia
• Dilated veins on chest wall

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5. ABDOMINAL EXAMINATION

A. INSPECTION (Patient supine, arms by side, knees slightly flexed)

• Scaphoid (sunken) — malnutrition, advanced malignancy
• Distended — ascites, obesity, organomegaly, gas, pregnancy (5 F's + 1 F: Fat, Fluid, Flatus, Faeces, Fetus + Fictitious)
• Localised bulge — organomegaly, hernia, mass

• Dilated veins:
  • Caput medusae (radiates from umbilicus) — portal HTN
  • Inferior vena cava obstruction (flow upward in flanks)
  • Superior vena cava obstruction (flow downward)
• Striae (silvery/white = old; purple = Cushing's)
• Visible peristalsis — gastric outlet obstruction, intestinal obstruction
• Scars (note operative, laparoscopic port scars)
• Umbilicus — inverted (normal) vs everted (ascites, obesity)
• Sister Mary Joseph nodule (periumbilical nodule = metastatic malignancy)
• Hernia — umbilical, inguinal, incisional
• Jaundice of skin
• Ecchymosis — Grey Turner's sign (flanks = retroperitoneal bleed/pancreatitis), Cullen's sign (periumbilical = same)

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B. PALPATION

Superficial Palpation

• Tenderness (localise to quadrant)
• Guarding (voluntary vs involuntary)
• Rigidity (board-like = peritonitis)

Deep Palpation

• Deeper tenderness
• Masses (note: position, size, shape, surface, margins, consistency, mobility, tenderness, pulsatility, movement with respiration)

Liver Palpation

• Start RIF, move toward right costal margin
• Ask patient to breathe deeply
• Normal: liver edge may be felt up to 2 cm below right costal margin
• Note: size below costal margin, surface (smooth/nodular), edge (sharp/rounded/irregular), consistency (soft/firm/hard), tenderness
• Hepatomegaly = >2 cm below costal margin

Spleen Palpation

• Start RIF, move toward left costal margin (diagonally)
• Ask patient to breathe deeply
• Normal spleen: not palpable
• If not felt supine → palpate in right lateral decubitus position
• Splenic notch felt on medial border = confirms spleen
• Differentiate from left kidney: cannot get above it (spleen), moves with respiration, notch present, dull to percussion, bimanual ballotability absent

Kidney Palpation (Bimanual)

• Ballotable, can get above it, resonant (colonic gas over it), does not move with respiration much

Other Masses

• Murphy's sign (cholecystitis): arrest of deep inspiration on palpating RHC
• McBurney's point tenderness (appendicitis)
• Rebound tenderness (peritonism)
• Rovsing's sign (appendicitis)

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C. PERCUSSION

Liver

• Liver span in MCL:
  • Normal: 6-12 cm

  • 12 cm = hepatomegaly

  • <6 cm = shrunken liver (cirrhosis/acute liver failure)
• Upper border: 5th ICS (MCL) / level of right nipple
• Lower border: right costal margin

Spleen

• Traube's space (left lower chest, bounded by 6th rib above, MAL laterally, left costal margin below) — normally resonant
• Dull Traube's space = splenomegaly or pleural effusion

Ascites

• Shifting dullness (most reliable clinical sign):
  • Percuss from umbilicus to flank - note where dullness begins
  • Patient turns to opposite side - wait 30 seconds
  • Re-percuss - if dullness shifts to dependent side = positive
  • Detects >500 mL of fluid
• Fluid thrill (large ascites >2L):
  • One hand on flank, flick opposite flank
  • Assistant places edge of hand in midline to dampen fat vibrations
  • Feel transmitted wave

General

• Tympanic over bowel (gas)
• Dull over solid organs/masses
• Obliteration of hepatic dullness = gas under diaphragm (perforation)

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D. AUSCULTATION

• Bowel sounds:
  • Normal: 5-12/minute, gurgling
  • Absent: paralytic ileus, peritonitis
  • High-pitched/tinkling: mechanical obstruction
  • Hyperactive: gastroenteritis, early obstruction
• Bruits:
  • Over liver = hepatocellular carcinoma, hepatic arteriovenous fistula
  • Over aorta = aortic aneurysm
  • Renal bruits = renovascular HTN
• Venous hum in epigastrium/umbilicus = portal HTN (Cruveilhier-Baumgarten syndrome)
• Rub over liver/spleen = hepatic/splenic infarction, perihepatitis (Fitz-Hugh-Curtis syndrome)
• Succussion splash (heard 3+ hours after meals) = gastric outlet obstruction

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6. GROIN & GENITALIA

• Inguinal lymph nodes (enlargement)
• Inguinal/femoral hernia
• Testicular atrophy (CLD)
• Scrotal oedema (ascites, hypoalbuminaemia)

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7. RECTAL EXAMINATION (PR) — mention even if not performed

• Inspect perianal area: haemorrhoids, fistula, fissure, skin tags
• Tone of sphincter
• Palpate rectal wall — mass, tenderness
• Prostate in males
• Blood, mucus on glove

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8. TO COMPLETE EXAMINATION

"To complete my examination, I would like to:

• Examine the hernial orifices
• Perform a per rectal examination
• Check external genitalia
• Examine the back and renal angles (costovertebral angle tenderness)
• Do relevant investigations: LFT, USG abdomen, endoscopy, ascitic tap, etc."

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QUICK SUMMARY TABLE — What Examiner Will Ask

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History Taking — Liver Pathology

MBBS Final Year Practical Exam

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OPENING

"Good morning sir/madam. I am a final year MBBS student. I would like to ask you some questions about your illness. May I proceed?"

• Name, Age, Sex, Occupation, Address, Religion, Marital status, Date of admission

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1. CHIEF COMPLAINTS

• Yellowish discolouration of eyes/skin (jaundice)
• Swelling of abdomen (ascites)
• Swelling of feet (pedal oedema)
• Pain/discomfort in right upper abdomen
• Nausea, vomiting
• Loss of appetite (anorexia)
• Weakness, fatigue
• Fever
• Altered behaviour / confusion (encephalopathy)
• Itching (pruritus — cholestatic)
• Dark urine / clay-coloured stools
• Haematemesis / melaena (variceal bleed)
• Weight loss

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2. HISTORY OF PRESENTING ILLNESS (HOPI)

For each complaint ask: SOCRATES

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A. JAUNDICE (if present)

• Sudden vs gradual
• Duration

• Colour of urine: dark (bilirubinuria = obstructive/hepatocellular) vs normal
• Colour of stools: clay/pale (obstructive) vs normal/dark
• Itching (pruritus) — prominent in obstructive/cholestatic jaundice

• Fever + rigors before jaundice → Charcot's triad = cholangitis (fever + jaundice + RUQ pain)
• Painless progressive jaundice → carcinoma head of pancreas
• Jaundice + anorexia + low-grade fever → viral hepatitis
• Jaundice + abdominal pain + vomiting + alcohol → alcoholic hepatitis
• Jaundice + weight loss + anorexia → malignancy
• Jaundice that waxes and wanes → haemolytic or stone disease
• Preceded by prodrome (malaise, nausea, low-grade fever 1-2 wks before) → viral hepatitis

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B. ASCITES / ABDOMINAL SWELLING (if present)

• Onset: sudden or gradual
• Duration
• Rate of progression: rapid (malignancy, SBP) vs slow (cirrhosis)
• Symmetrical or asymmetrical
• Associated with:
  • Pedal oedema
  • Breathlessness (diaphragm splinting, hepatic hydrothorax)
  • Decreased urine output (hepatorenal syndrome)
  • Fever + abdominal pain → spontaneous bacterial peritonitis (SBP)
  • Weight gain
• Previous tapping (paracentesis) — how many times, how much drained
• Response to diuretics

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C. PAIN ABDOMEN (if present)

• Site: Right hypochondrium / epigastrium / generalised
• Onset: sudden (perforation, bleed) vs gradual
• Character:
  • Dull aching (hepatomegaly, capsule distension)
  • Colicky (biliary colic — comes in waves, radiates to right shoulder/back)
  • Constant severe (cholecystitis, abscess, malignancy)
• Radiation: right shoulder/scapula tip (biliary/diaphragm irritation)
• Aggravating: fatty food (biliary disease)
• Relieving: posture, antacids
• Associated: fever, nausea, vomiting, jaundice

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D. HAEMATEMESIS / MELAENA (if present)

• Amount of blood vomited (teaspoon/cup/bowl)
• Fresh red blood vs coffee-ground
• Melaena (black tarry stools) — confirms upper GI bleed
• Haematochezia (fresh blood PR) — lower GI or massive upper GI bleed
• Associated with known portal HTN, varices, previous episodes
• Precipitated by: alcohol binge, vomiting (Mallory-Weiss if after prolonged retching)
• Haemodynamic status: giddiness, palpitations, syncope

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E. ALTERED SENSORIUM / CONFUSION (if present)

• Onset: sudden or gradual
• Fluctuating or constant (encephalopathy fluctuates)
• Precipitants:
  • GI bleed
  • Infection
  • Constipation
  • Excess protein intake
  • Sedatives / tranquillizers
  • Electrolyte disturbance
  • Dehydration
  • Renal failure
• Previous episodes
• Sleep disturbance (reversal of sleep-wake cycle — early HE)
• Change in personality, behaviour (family members' observation)
• Fetor hepaticus noticed

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F. FEVER (if present)

• Duration, pattern
• Rigors/chills
• Associated with jaundice → cholangitis
• Associated with ascites → SBP
• Associated with tender hepatomegaly → amoebic/pyogenic liver abscess
• Evening rise of temperature → TB (also causes hepatomegaly)

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G. PRURITUS (if present)

• Duration, generalised or localised
• Worse at night
• Relieved by scratching or not
• Suggests cholestatic jaundice (PBC, PSC, obstructive)
• Scratch marks on skin

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H. WEIGHT LOSS & ANOREXIA

• Amount of weight lost (in kg) over what period
• Anorexia: specific aversion to fat (cholecystitis), meat (hepatitis), alcohol
• Associated fatigue
• Malignancy: rapid weight loss + anorexia + jaundice = red flags

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3. PAST HISTORY

• Previous episodes of jaundice
• Previous liver disease / hepatitis (type A, B, C, E)
• Previous abdominal surgeries (cholecystectomy, splenectomy, hepatectomy, Whipple's)
• Blood transfusions (risk for HBV, HCV)
• Diabetes mellitus (NAFLD)
• Hypertension
• Tuberculosis (hepatic TB, anti-TB drug hepatotoxicity — RIPE drugs)
• Malaria (hepatomegaly, Blackwater fever)
• Sickle cell disease / haemolytic anaemia
• Known cardiac disease (right heart failure → congestive hepatomegaly)
• Wilson's disease / haemochromatosis (hereditary)
• Autoimmune disorders (AIH, PBC)
• Previous hospital admissions and treatment

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4. DRUG HISTORY

• Always ask about herbal/traditional medicines (common in India, often not volunteered)
• Duration of drug use

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5. PERSONAL HISTORY

Alcohol History (CAGE Questionnaire + Quantification)

• Have you ever felt you should Cut down on drinking?
• Have people Annoyed you by criticising your drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a drink first thing in the morning (Eye-opener)?

2 or more YES = significant alcohol use disorder

• Type of alcohol consumed (country liquor, beer, wine, spirits)
• Amount per day (standard units): 1 unit = 10 mL pure alcohol
• Duration (in years)
• Daily vs binge drinking
• Last drink consumed (important for withdrawal risk)
• Hepatotoxic threshold: >80 g/day in men, >40 g/day in women for >5 years

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Smoking / Tobacco

• Smoking (number of pack-years) — risk for malignancy
• Tobacco chewing

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Diet History

• Vegetarian or non-vegetarian
• Fat intake (biliary disease)
• Protein intake (relevant in encephalopathy)
• Contaminated water / street food (Hepatitis A, E — faeco-oral)
• Raw shellfish consumption (Hepatitis A, E)
• Malnutrition

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Sexual History (sensitively)

• Multiple sexual partners (risk for HBV, HCV, HIV)
• Commercial sex worker contact
• Homosexual behaviour (HBV risk)

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IV Drug Use

• Intravenous drug abuse (major risk factor for HBV, HCV, HIV)
• Needle sharing

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Occupation

• Healthcare worker (needle-stick injury, HBV/HCV risk)
• Exposure to chemicals/solvents (carbon tetrachloride, vinyl chloride = hepatotoxic)
• Farmer (Weil's disease/leptospirosis)
• Travel history (endemic areas for Hepatitis A/E, malaria, schistosomiasis, echinococcus)

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Tattooing / Body Piercing / Ear Piercing

• HBV and HCV transmission risk

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Menstrual History (in females)

• Last menstrual period (rule out pregnancy — AFLP, hyperemesis)
• OCP use (cholestasis, hepatic adenoma, Budd-Chiari syndrome)

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6. FAMILY HISTORY

• Similar illness in family members:
  • Jaundice in siblings/parents (viral hepatitis clusters — Hep A/E outbreaks)
  • Haemolytic anaemia, sickle cell, thalassaemia
• Wilson's disease (autosomal recessive)
• Haemochromatosis (autosomal recessive)
• Alpha-1 antitrypsin deficiency (autosomal codominant)
• Hepatocellular carcinoma in family (HBV-related vertical transmission)
• Gilbert's syndrome (benign familial jaundice)

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7. SOCIOECONOMIC HISTORY

• Socioeconomic status (lower = risk for Hep A/E, malnutrition, alcoholism)
• Housing — overcrowding (Hep A/E)
• Sanitation and clean water access
• Financial impact of illness
• Social support system (important for counselling in chronic disease)

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8. IMMUNISATION HISTORY

• Hepatitis B vaccination status (3 doses)
• Hepatitis A vaccination
• Important for healthcare workers and contacts

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CLOSING THE HISTORY

"Thank you for answering my questions. Is there anything else you would like to tell me that you think is important?"

• General examination
• Systemic examination (GI — as above)

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QUICK POINTER TABLE — History Clues to Diagnosis

History Taking — Liver Pathology

(20-minute exam version)

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BIODATA

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CHIEF COMPLAINTS (with duration)

• Jaundice / Yellow eyes
• Abdominal swelling
• Pedal oedema
• RUQ pain
• Nausea, vomiting, anorexia
• Fever
• Dark urine / pale stools
• Haematemesis / melaena
• Confusion / altered behaviour
• Pruritus, weight loss, fatigue

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HOPI

Jaundice

• Onset, duration, progressive or fluctuating
• Urine: dark | Stool: clay-coloured → obstructive
• Pruritus → cholestatic
• Fever + RUQ pain + jaundice → Charcot's triad (cholangitis)
• Painless + progressive + elderly → Ca pancreas
• Prodrome + contaminated water → viral hepatitis
• Alcohol + vomiting → alcoholic hepatitis

Ascites

• Onset, rate of progression
• Breathlessness, decreased urine output
• Fever + abdominal pain → SBP
• Previous tapping — how many times

Pain Abdomen

• Site, character (colicky = biliary; dull = capsule distension)
• Radiation to right shoulder (biliary)
• Aggravated by fatty food

Haematemesis

• Amount, fresh red vs coffee-ground
• Melaena present or not
• Giddiness / syncope (haemodynamic instability)

Confusion

• Fluctuating → hepatic encephalopathy
• Precipitants: GI bleed / infection / constipation / sedatives / electrolyte imbalance
• Sleep reversal (early sign)

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PAST HISTORY

• Previous jaundice / hepatitis / liver disease
• Blood transfusions
• Abdominal surgeries
• DM (NAFLD), TB (drug hepatotoxicity), cardiac disease (congestive hepatomegaly)
• Malaria, sickle cell, haemolytic anaemia

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DRUG HISTORY (hepatotoxic drugs)

• Anti-TB — INH, Rifampicin, PZA ← most important
• Herbal/Ayurvedic ← ask specifically
• NSAIDs (paracetamol overdose)
• Statins, Amiodarone, OCP
• Methotrexate, Valproate

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PERSONAL HISTORY

• Cut down? | Annoyed? | Guilty? | Eye-opener? (≥2 = significant)
• Amount/day, duration, last drink
• Threshold: >80 g/day men, >40 g/day women for >5 yrs

• IV drug use / needle sharing
• Multiple sexual partners
• Blood transfusion / tattooing / piercing
• Healthcare worker (needle-stick)

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FAMILY HISTORY

• Similar jaundice (Hep A/E outbreaks, Gilbert's)
• Wilson's disease / Haemochromatosis / α1-AT deficiency (AR inheritance)
• HBV (vertical transmission → HCC in family)

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SOCIOECONOMIC HISTORY

• Overcrowding, poor sanitation → Hep A/E
• Financial status, social support

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IMMUNISATION

• Hepatitis B — 3 doses given or not
• Hepatitis A

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QUICK CLUE TABLE

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End with: "To complete history I would ask about review of systems and then proceed to general and systemic examination."

History Taking — Respiratory Case

MBBS Final Year Practical Exam

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BIODATA

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CHIEF COMPLAINTS (in patient's words, with duration)

• Cough
• Breathlessness / Dyspnoea
• Chest pain
• Haemoptysis
• Fever
• Wheezing
• Hoarseness of voice
• Weight loss / Anorexia
• Swelling of face / neck
• Noisy breathing (stridor)

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HOPI

1. COUGH

• Onset: Sudden vs gradual
• Duration: Acute (<3 wks) | Subacute (3-8 wks) | Chronic (>8 wks)
• Character:
  • Dry / non-productive → ILD, early LVF, ACE inhibitor, pleural effusion
  • Productive → bronchiectasis, COPD, lung abscess, TB
  • Brassy/loud → tracheal compression, laryngeal
  • Barking → croup (children), epiglottitis
  • Bovine (no explosive phase) → RLN palsy
  • Whooping → pertussis
• Timing:
  • Morning → bronchiectasis, COPD (daily morning mucopurulent)
  • Night → asthma, LVF, GORD
  • On lying down (orthopnoeic cough) → LVF, bronchiectasis
  • Positional (one side) → lung abscess, bronchiectasis
• Sputum (if productive):
  • Amount per day (bronchiectasis: copious, >200 mL/day)
  • Colour: white/clear (viral, asthma) | yellow/green (bacterial) | rust-coloured (pneumococcal pneumonia) | currant jelly (Klebsiella) | pink frothy (pulmonary oedema) | black (coal miners) | anchovy sauce (amoebic abscess)
  • Smell: foul/offensive → lung abscess, bronchiectasis
  • Three-layer sputum on standing → bronchiectasis
  • Blood in sputum → see haemoptysis

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2. BREATHLESSNESS / DYSPNOEA

• Onset: Sudden vs gradual
• Grading (MRC scale):

• Character:
  • Episodic + wheezing → asthma
  • Progressive + chronic smoker → COPD
  • Sudden onset → pneumothorax, PE, acute asthma
  • Orthopnoea (flat position) → LVF, severe asthma
  • PND (wakes from sleep) → LVF, asthma (3 AM dip)
  • Platypnoea (worse on sitting up, better lying) → hepatopulmonary syndrome, ASD
  • Trepopnoea (worse on one side) → pleural effusion, unilateral lung pathology
• Diurnal variation: Worse in morning → COPD | Worse at night → asthma
• Precipitants: Exercise | Allergens | Dust | Cold air | Fumes | NSAIDs (aspirin-sensitive asthma) | Beta-blockers

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3. CHEST PAIN

• Site: Localised vs diffuse
• Onset: Sudden (pneumothorax, PE) vs gradual
• Character:
  • Sharp, stabbing, worse on breathing/coughing → pleuritic (pleuritis, pneumonia, PE, pneumothorax)
  • Dull aching, constant → malignancy, mediastinal
  • Central crushing → cardiac (distinguish from respiratory)
  • Burning retrosternal → GORD
• Radiation: To shoulder (diaphragmatic pleuritis) | To arm/jaw (cardiac)
• Aggravating: Deep breathing, coughing, movement → pleuritic
• Relieving: Leaning forward → pericarditis / pericardial effusion

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4. HAEMOPTYSIS

• Onset, duration, episodes
• Amount: Streaky | Cupful | Frank (>200 mL/24h = massive haemoptysis)
• Colour: Bright red (fresh) | Dark (old) | Pink frothy (pulmonary oedema — not true haemoptysis)
• Mixed with sputum or pure blood
• Associated with:
  • Cough + weight loss + evening fever → TB ← most common cause in India
  • Recurrent + copious sputum → bronchiectasis
  • Elderly + smoker + weight loss → lung carcinoma
  • Young + mitral stenosis → MS with pulmonary HTN
  • Sudden onset + pleuritic pain + risk factors → pulmonary embolism
  • Rusty sputum + fever + pleurisy → pneumococcal pneumonia
• Rule out: Haematemesis (mixed with food, pH acidic, melaena) | Epistaxis (blood from nasopharynx)

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5. FEVER

• Duration, pattern
• Evening rise + night sweats + weight loss → TB (classic)
• High fever + rigors + rust-coloured sputum → pneumonia
• Low-grade + chronic cough → TB, malignancy
• Fever + pleuritic pain → pleuritis, empyema
• Recurrent fever + purulent sputum → bronchiectasis, lung abscess

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6. WHEEZE

• Onset, episodic or continuous
• Precipitants: allergens, exercise, cold, fumes, drugs
• Relieved by bronchodilators → asthma
• Persistent unilateral wheeze (monophonic) → foreign body, tumour (fixed obstruction)
• Polyphonic diffuse wheeze → asthma, COPD
• Inspiratory stridor → upper airway obstruction (larynx, trachea)

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PAST HISTORY

• Previous similar episodes (asthma — recurrent from childhood)
• Previous TB and treatment taken (duration, compliance, DOT)
• Previous hospitalisation / ICU admission for breathing difficulty
• Childhood respiratory illness (recurrent LRTI → bronchiectasis)
• Tuberculin test / Mantoux done previously
• Allergic disorders — eczema, allergic rhinitis, urticaria (atopic triad with asthma)
• Cardiac disease (LVF → pulmonary oedema, cardiac asthma)
• Malignancy elsewhere (lung mets)
• Surgery / immobilisation / long travel (DVT → PE)
• HIV status (TB, PCP, fungal infections)
• Diabetes (TB, mucormycosis, susceptibility to infection)

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DRUG HISTORY

• Current inhalers — SABA, LABA, ICS, LAMA (type and frequency)
• Oral steroids — current / previous use
• Nebuliser use at home

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PERSONAL HISTORY

Smoking (most important in respiratory history)

• Quantify in pack-years:

  Pack-years = (cigarettes per day ÷ 20) × years smoked

• Type: cigarettes | bidi | hookah | pipe
• Age started, duration
• Current smoker or ex-smoker (if stopped — when and why)
• >10 pack-years → significant risk for COPD, lung Ca
• Passive smoking — household exposure

Occupation (very important — always ask)

• Duration of occupational exposure
• Use of protective equipment (mask)

Residence / Environment

• Urban (pollution → COPD, asthma) vs rural
• Indoor cooking with biomass fuel / wood fire / cowdung cakes → COPD in women (common in India)
• Animal exposure at home (dog, cat, bird → allergic asthma, HP)
• Overcrowding → TB transmission
• Damp housing → mould → asthma

Diet

• Nutritional status (TB — malnourished)
• Alcohol (aspiration pneumonia, TB risk)

Travel history

• Endemic areas for TB, histoplasmosis, coccidioidomycosis
• Long-haul flights (PE risk)

Sexual history

• HIV risk (TB, PCP, CMV pneumonitis)

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FAMILY HISTORY

• TB in household contacts (close contact = high risk)
• Asthma (strong genetic predisposition)
• Atopy — eczema, allergic rhinitis, food allergy in family
• Cystic fibrosis (AR — recurrent chest infections from childhood)
• Alpha-1 antitrypsin deficiency (AR — early onset emphysema)
• Malignancy (lung cancer family history)
• ILD (familial pulmonary fibrosis)

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SOCIOECONOMIC HISTORY

• Overcrowding, poor ventilation → TB
• Low SES → malnutrition → TB susceptibility
• Biomass fuel use (major COPD risk in Indian women)
• Financial ability for treatment and follow-up
• Compliance with previous treatment (TB — very important)

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IMMUNISATION HISTORY

• BCG vaccination (scar present or not) — TB
• Influenza vaccine (annually for COPD, elderly, immunocompromised)
• Pneumococcal vaccine (COPD, elderly, asplenic)
• COVID-19 vaccination

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REVIEW OF SYSTEMS (quickly)

• CVS: ankle swelling, palpitations (cor pulmonale, PE)
• GIT: heartburn, regurgitation (GORD → chronic cough, aspiration)
• Neurology: any weakness (neuromuscular → respiratory failure)
• ENT: nasal discharge, post-nasal drip, sinusitis (upper airway → chronic cough)

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CLOSING

"Thank you. Is there anything else you would like to tell me? I will now proceed to general and systemic examination."

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QUICK CLUE TABLE