CASE PRESENTATION ON JAUNDICE

CASE PRESENTATION OF JAUNDICE INCLUDES PATIENT DEMOGRAPHICS, PAST MEDICAL AND MEDICATION HISTORY, FAMILY HISTORY, SURGICAL HISTORY, PERSONAL HISTORY, ON EXAMINATION, LABORATORY INVESTIGATIONS, DIAGNOSIS, SOAP NOTES, TREATMENT, DISEASE INFORMATION, PATIENT COUNSELLING, LIFE STYLE MODIFICATIONS.

1. CASE PRESENTATION ON JAUNDICE Presented By : M . DurgaRohitha 174T1T0005 Pharm D VI Year

2. PATIENT DETAILS A male patient with 51 years of age was admitted in the general Medical Ward with chief complaints – Fever with chills since 1 day Swollen foot, after one day a black patch and water bubbles are appeared Vomtings since 1 day HISTORY OF PRESENT ILLNESS: Vomtings with food particles is seen Fever and chills are observed with on & off Edema is pitting type Decreased fluid and food intake Decreased sleep from past 1 day Yellowish colour of eyes are seen

3. PAST MEDICAL HISTORY Known case of Hypertension since 12 years and using Bisoprolol Fumerate 5mg Known case of Diabetes Mellitus since 1 year and using Metformin Hydrochloride Prolonged-Release And Glimepiride Tablets 1mg. FAMILY HISTORY Diabetes Mellitus – present to his father SURGICAL THERAPY Nill significant PERSONAL HISTORY H abits – smoking ; - alcoholic ; - Food ; VEG Appetite & sleep – Decreased Bowel & Bladder - Normal

4. ON EXAMINATION VITALS OBSERVED VALUE NORMAL VALUE Temperature 99.6 F 98.6 F Pulse rate 78bpm 72bpm SPO2 95% 98% BP 120/80mm of Hg 120/90mm of Hg pallor -- - Icterus + - Edema extremities + pitting type Edema seen in lower right foot -

5. LABORATORY EXAMINATIONS PARAMETERS OBSERVED VALUES NORMAL VALUES Hemoglobin 10.4 gm/dl 13 – 16 gm/dl RBC 4.5 m/ cumm 4.75 – 6.0 m/ cumm Packed cell volume 35.8 % 38 – 50 % MCV 79.2 fl 74 – 95 fl MCH 22.6 Pg 27 – 32 Pg MCHC 28.8 gm/dl 31.8 – 36.3 gm/dl Platelet count 1,39,000cells/ cumm 1.4 – 4.5lakh cells/ cumm ESR 15mm/ hr 0 – 10mm/ hr Total Leucocyte count 21,200/ cumm 4000 – 10,000/ cumm Conjugated Bilirubin 0.6 mg/dl 0.0 – 0.2 mg/dl Unconjugated Bilirubin 2.4 mg/dl 0.2 – 0.8 mg/dl Total Bilirubin 3.0 mg/dl 0.2 – 1.0 mg/dl

6. FBS 76 mg/dl 70 – 110 mg/dl PPBS 92 mg/dl 80 – 150 mg/dl URINE ANALYSIS ; Appearance Turbid Colour Red pus cells + - Epithelial cells + - RBC + - Continued…., Serology Report : Specimen: Serum for salmonella T yphi antibody screening test Result: salmonella Typhi “0” 1:160dil, salmonella “H” 1:160dil, salmonella paratyphi “AH” 1:20dil salmonella paratyphi “BH” 1:20 dil Normal range is upto 1: 80dil.

7. DIAGNOSIS By observing chief complaints and laboratory investigations the patient was diagnosed to have CELLULITIS WITH JAUNDICE

8. SOAP NOTES SUBJECTIVE ; Fever with chills since 1 day Swollen foot, after one day a black patch and water bubbles are appeared Vomiting's since 1 day OBJECTIVE ; Vomiting's with food particles Fever on and off Edema is pitting type Hemoglobin : 10.4 gm/dl ESR : 15 Unconjugated bilirubin : 2.4 mg/dl Total bilirubin : 3.0 mg/dl Urine Analysis – color ; red pus cells ; + Epithelial cells ; + RBCs ; +

9. ASSESSMENT JAUNDICE

10. PLAN BRAND NAME GENERIC NAME DOSE ROA FREQ DAYS OF TMT Ursokem T.Ursodeoxycholic acid 300mg oral BD 5 days Pacimol T. Paracetomol 650mg oral TID 5 days Rantac T. Ranitidine 40mg oral OD 3 days Zerodol - SP Aceclofenac 325mg oral BD 4 days Megazolid Linezolid 300ml IV BD 4 days Metrogyl Metronidazole 100ml IV BD 4 days Periset Ondansetron 4mg IV OD 4 days

11. DEFINITION Jaundice is also called as a hyperbilirubinemia. It is a yellow discoloration of the body tissue resulting from the accumulation of an excess of bilirubin. Excess of bilirubin indicates increased production or impaired excretion. Normal serum bilirubin ; 1.2 mg/dl. Further increase in serum bilirubin levels , skin will progressively discolour ranging from lemon yellow to apple green especially if the process is long standing the green colour is due to bilirubin. Bilirubin contains unconjugated bilirubin ( Indirect ) conjugated bilirubin ( Direct ). ETIOLOGY CONJUGATED HYPERBILIRUBINEMIA Dubin Johnson syndrome Rotor syndrome Hepatocellular disease – viral hepatitis, alcoholic hepatitis, cirrhosis, Wilson autoimmune disease Infiltrative disease – Amyloidosis, lymphoma, sarcoidosis. TPN Drugs and toxins – oral contraceptives, rifampicin, probenecid, steroids, chlorpromazine, herbal medications. DISEASE INFORMATION

12. 2. BILIARY OBSTRUCTION Choledocholithiasis Tumors Acute and chronic pancreatitis Parasitic infections ( Ascaris ) 3. UNCONJUGATED Hemolytic anemia – Gilbert syndrome Crigler – Najjar syndrome SIGNS AND SYMPTOMS Common signs and symptoms seen in individuals with jaundice include : Yellow discoloration of *Abdominal pain The skin *Fever Mucous membranes * Weakness The whites of the eyes * Loss of appetite Light – colored stools *headache Dark-colored urine Itching of the skin Nausea & vomiting

13. TYPES Prehepatic ; Arising from the blood, before it enters the liver Excess production of bilirubin due to excess breakdown of hemoglobin Indirect bilirubin ( insoluble in water since unconjugated) Intrahepatic ; Due to disease of liver parenchyma Liver ability to conjugate or excrete bilirubin is affected Increased level of conjugated and unconjugated bilirubin present. Post hepatic ; Result of obstruction of biliary tract outside the liver. Bilirubin formation rate is normal

14. DIAGNOSIS Physical Examination Complete blood count Bilirubin tests Hepatitis A,B & C tests – This tests for a range of liver infections.

15. TREATMENT Goals The  goal  of treating  jaundice  is to efficiently and safely reduce the level of bilirubin . Minimizing development or severity of associated complications NON pharmacological therapy Drink at least eight glasses of fluids per day . Consider adding milk thistle to your routine . Eat  at least 2 & 1/2 cups of veggies and 2 cups of fruit per day. Look for high-fiber  foods , such as oatmeal, berries, and almonds . Pharmacological therapy Jaundice treatment targets the cause rather than the jaundice symptoms The following treatments are used Anemia-induced jaundice may b e treated by boosting the amount of iron in the blood by either taking iron supplements or eating more iron-rich foods. Hepatitis-induced jaundice requires antiviral ( Acyclovir) or steroid medications ( methylprednisolone , prednisolone) O bstruction-induced jaundice by surgically removing the obstruction. If the jaundice has been caused by use of the medication, treatment involves changing to an alternative medications.

16. Ursodeoxycholic acid is mainly given for jaundice and it is a hepatoprotectant . Paracetomol is mainly given to reduce body temperature Ranitidine is mainly neutralizes the acid secretion in stomach. Aceclofenac is given mainly for the pain of punchered cellulitis. Linizolide is an antibiotic. Metronidazole is a antibacterial agent. Ondansetron is to reduce / stop vomtings .

17. CRITICAL EVALUATION Clinical condition : Jaundice with cellulitis Drug of choice : Ursodesoxycholic acid Drugs : All are appropriate Doses : All are appropriate Dosage form : All are appropriate Frequency : All are appropriate Duration : All are appropriate Guidelines : clinicalestablishments.gov.in Drug interactions ; no drug interactions

18. PATIENT COUNSELLING Drink 6 – 8 glasses of water per day Eat lots of vegetables like leafy vegetables Liquid (Juices)intake is necessary for speed recovery. Do not dink coffee, alcohol , soda and other junk food and drinks. Brown rice and millets are good. Avoid red meet and animal fats. Get sleep and do some exercise for health( walking for digestion). And take medicines as Doctor suggests as regular.

19. Reference https://WWW.ncbi.nlm.nih.gov/books/NBK544252/