Following is my Case presentation On Hepatitis Case

1. MEDICO-SOCIAL CASE
ON HEPATITIS
Presented by: Dr. Kunal
Guided By: Dr. Abhay Mudey
6/19/2016 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
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3. SOCIO ECONOMIC HISTORY
 Education : 10th 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
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4. CHIEF COMPLAINTS
 Patient came to hospital on 16th of May 2016, with chief
complaints of ;
1) Vomiting 3 episodes X 2days
2) Loose Stools 3 episodes X 2 days
3) Abdominal Pain X 2 days
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5. H/O PRESENT ILLNESS
 Patient was apparently alright 2 days back, when she had vomiting
3episodes in evening on 15th 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.
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6. CONTINUED
 Patient also complains of abdominal pain with 1st 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.
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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.
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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
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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.
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10. FAMILY COMPOSITION
Name Relation Age Education Occupation
Raju Husband 27 10th Pass Mason
(Cement
Mistry)
Sarika Self 21 10th Pass Homemaker
Gayabai Mother in
law
46 Illiterate Homemaker
Ranjeet Brother in
law
22 12th Pass Farmer
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11. MENSTRUAL HISTORY
 Normal Regular/ 28 days
 4-5 days cycle
 No dysmenorrhoea
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12. DIETARY HISTORY
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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
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14. CONTINUED….
 Energy requirement is ≈2230 kcal.
 Energy deficit is ≈ 1086 kcal
 Protein requirement is ≈ 37 gms
 Protein deficit is ≈ 15.2 gms
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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.
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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.
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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
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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
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19. CONTINUED….
 BMI : 18.29
 Pallor : Present
 Icterus : Present
 Lymph nodes : Absent
 Clubbing : Absent
 Oedema : Absent
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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.
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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
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22. CONTINUED….
 Percussion :-
Normal tympanic note heard.
Shifting dullness absent.
 Auscultation :-
Normal bowel sound heard.
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23. CONTINUED….
 Respiratory System :-
 Air entry equal on both sides.
 No additional sounds heard.
 CVS:
 S1 S2 heard, No murmur.
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24. CONTINUED….
 CNS:-
 Patient well oriented to time place & person.
 No neurological deficit found .
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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.
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26. DIFFERENTIAL DIAGNOSIS
 Liver Cirrhosis
 Cholangitis
 Liver Abscess
 Hepatocellular Carcinoma
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27. PROVISIONAL DIAGNOSIS
 21 year old female, Sarika Raju Janjal with mild dehydration
suspected to be a case of Viral Hepatitis.
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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
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29. CONTINUED….
 Prothrombin time : 139
 Alkaline Phosphatase : 310
 Serum Creatinine : 0.56
 Sodium : 142
 Potasium : 4.3
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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.
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31. CONTINUED….
 Urine examination for bile & Bile salts.
 USG :-
Borderline hepatomegaly with liver parenchymal disease.
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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
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33. TREATMENT ADVICE &
FOLLOW UP AT FAMILY LEVEL
 Advice Preventive measures
 Hand washing
 Cleaning of foods
 Purification of water
 Disinfection of water
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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.
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35. RECOMMENDATIONS
 Hand washing
 Food hygiene
 Avoiding food from street vendors
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