Hepatitis case

Following is my Case presentation On Hepatitis Case

1. Medico-Social Case On Hepatitis Presented by: Dr. Kunal Guided By: Dr. Abhay Mudey 6/1/2016 1

2. Name: Sarika Raju Janjal Age- 21 years, Sex: Female Religion: Hindu, Cast: Kunbi (OBC) Address: Ward No-1, Near Mahadev Mandir , Peth Raghunathpur , Mangrul Dastagigir Taliuka , Amarawati-444711 Date of admission : 16/05/2016 Date of Examination : 17/05/2016 Admitted in : Ward No-27, Medicine Ward Bed No: 14 General Information 6/1/2016 2

3. Socio Economic History Education : 10 th Pass Occupation : Homemaker Total annual Family income: Rs.50,000/-(From all sources) Total No. of family member in the house : 4 Per Capita Income per month : Rs. 1041/capita/month Socio economic status : According to Modified B.G Prasad’s Classification – Class IV 6/1/2016 3

4. Chief Complaints Patient came to hospital on 16 th of May 2016, with chief complaints of ; Vomiting 3 episodes X 2days Loose Stools 3 episodes X 2 days Abdominal Pain X 2 days 6/1/2016 4

5. H/o present illness Patient was apparently alright 2 days back, when she had vomiting 3episodes in evening on 15 th may after taking meal , the vomiting was non projectile, containing food particles & water, without any presence of blood in vomitus , no foul smell. She complains of loose stools containing semi digested food particles & water without any presence of blood in stool it was mainly watery & non mucoid in appearance. 6/1/2016 5

6. Continued Patient also complains of abdominal pain with 1 st episode of vomiting in the epigastric region, it was spasmodic type of pain, non radiating . H/O Patient visiting to her mothers place about 2 weeks back. No H/O fever / cough. 6/1/2016 6

7. Past history No similar complaints in the past. History of contact : absent No H/O blood transfusion, hypertension, Diabetes Mellitus, Asthma, Any chronic illness, or surgery. No H/O of substance abuse. 6/1/2016 7

8. Personal History Vegeterian diet Appetite reduced Bladder habits : Normal Yellow colour of urine Bowel Frequency of passing stools increased- 3 episodes Loose motions for 2 days 6/1/2016 8

9. Family History Family consist of 4 members. She lives with her husband & Mother in law, Brother in law. No history of similar complaints in family. No history of any chronic illness/DM/HTN/Asthma in the family. 6/1/2016 9

10. Family composition Name Relation Age Education Occupation Raju Husband 27 10 th Pass Mason (Cement Mistry ) Sarika Self 21 10 th Pass Homemaker Gayabai Mother in law 46 Illiterate Homemaker Ranjeet Brother in law 22 12 th Pass Farmer 6/1/2016 10

11. Menstrual history Normal Regular/ 28 days 4-5 days cycle No dysmenorrhoea 6/1/2016 11

12. Dietary History 6/1/2016 12

13. Dietary history CALORIES (Kcal) PROTEIN ( gms ) MORNING: TEA (1 CUP) ≈ 62 ≈ 1.0 LUNCH: CHAPATI (2) ≈ 180 (2 x 90) ≈ 3.0 (2 x 1.5) DAL (1 KATORI ) ≈ 75 ≈ 3.1 VEGETABLE ( 1 KATORI) ≈ 150 ≈ 1.7 RICE ( 1 KATORI ) ≈105 ≈ 2.1 EVENING: TEA (1 CUP) ≈ 62 ≈ 1.0 DINNER: CHAPATI (2) ≈ 180 ( 2X90 ) ≈ 3.0 (2X1.5) DAL (1 KATORI ) ≈ 75 ≈ 3.1 RICE ( 1 KATORI ) ≈105 ≈ 2.1 VEGETABLE ( 1 KATORI) ≈ 150 ≈ 1.7 TOTAL ≈ 1144 ≈ 21.8 6/1/2016 13

14. Continued…. Energy requirement is ≈2230 kcal. Energy deficit is ≈ 1086 kcal Protein requirement is ≈ 37 gms Protein deficit is ≈ 15.2 gms 6/1/2016 14

15. Environmental History Stays in kuccha house, roofed with tin sheet. 3 rooms in house. Each room has 1 room & 1 door. Separate kitchen. Toilet bathroom attached. Tap water from gram panchayat used for drinking & other purpose. Do not filter or boil drinking water. 6/1/2016 15

16. Continued…. Drinking water is stored in earthen pot ( Matka ) with lid & every time gadu is used to take water from pot. Garbage disposal in open field near the house. Sullage disposal in open kuccha drain beside the house. Fly nuisance present. No pets at home. 6/1/2016 16

17. Treatment history Inj. Pan 40 IV od Inj. Emset 4mg IV od Inj. D-25% IV od IVF. D-25% 500ml slow IV tds IVF. DNS O II IV stat IVF. RL O II IV stat Tab. UDILIVE tds 6/1/2016 17

18. General Examination Patient is cooperative, oriented to time, place & person. Patient is afebrile . Pulse : 64 /min Blood Pressure : 110/60 mmHg Respiratory rate : 17/ min Height- 4 feet 8 inches ( i.e 146.3 cm). Weight-37 kg 6/1/2016 18

19. Continued…. BMI : 18.29 Pallor : Present Icterus : Present Lymph nodes : Absent Clubbing : Absent Oedema : Absent 6/1/2016 19

20. Systemic Examination Abdominal Examination : Inspection :- Abdomen scaphoid shape Normally moving with respiration. Umbilicus inverted & centrally placed. No scar, No visible veins are present. Skin is dry. 6/1/2016 20

21. Continued…. Palpation :- Abdomen soft, Non tender, Liver firm smooth with distinct border. Palpable measuring about 2 fingers (2.5cm) from the lower costal margin. Spleen is non palpable 6/1/2016 21

22. Continued…. Percussion :- Normal tympanic note heard. Shifting dullness absent. Auscultation :- Normal bowel sound heard. 6/1/2016 22

23. Continued…. Respiratory System :- Air entry equal on both sides. No additional sounds heard. CVS: S1 S2 heard, No murmur. 6/1/2016 23

24. Continued…. CNS:- Patient well oriented to time place & person. No neurological deficit found . 6/1/2016 24

25. Case summary 21 year old female Sarika Raju Janjal , belonging to socio economic status class IV, living in kuccha house, with 2 rooms and does not boil & purify drinking water by any means, was admitted with complaints of vomiting, loose motions, pain in abdomen since 2 days & was under treatment as suspected case of viral hepatitis. 6/1/2016 25

26. Differential Diagnosis Liver Cirrhosis Cholangitis Liver Abscess Hepatocellular Carcinoma 6/1/2016 26

27. Provisional diagnosis 21 year old female, Sarika Raju Janjal with mild dehydration suspected to be a case of Viral Hepatitis. 6/1/2016 27

28. Investigations Hb % : 9.8 WBC : 7,100 Total Protein : 6.5 Albumin : 3.7 Globulin : 3.8 Total Albumin : 21.26 Direct albumin : 8.37 Indirect : 12.89 6/1/2016 28

29. Continued…. Prothrombin time : 139 Alkaline Phosphatase : 310 Serum Creatinine : 0.56 Sodium : 142 Potasium : 4.3 6/1/2016 29

30. Continued…. Liver function test : SGOT : 160 UI/lit SGPT : 180 UI/lit RBS : 78 mg/dl Stool Examination : Viral particles are seen under electron microscopy. 6/1/2016 30

31. Continued…. Urine examination for bile & Bile salts. USG :- Borderline hepatomegaly with liver parenchymal disease. 6/1/2016 31

32. Treatment & follow up at Individual Level Tab Norflox TZ BD X 3D Tab Buscopan SOS ORT & High Oral fluids adviced . Tab Pan D BD X 3D Tab.UDILIVE TDS X 15 D 6/1/2016 32

33. Treatment advice & follow up at Family Level Advice Preventive measures Hand washing Cleaning of foods Purification of water Disinfection of water 6/1/2016 33

34. Treatment advice ,follow up at Community level Health education Mass Media approach Breaking channel of transmission by constructing SANITATION BARRIER. Protection of susceptible by Immunization. 6/1/2016 34

35. Recommendations Hand washing Food hygiene Avoiding food from street vendors 6/1/2016 35

36. THANK YOU 6/1/2016 36