CASE PRESENTATION

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General Objectives

To present a comprehensive case discussion on patient with Hepatitis B using appropriate clinical approach.

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Specific Objectives

Enumerate and

Formulate a working diagnosis based

rule out differential Briefly present the history and diagnoses physical findings of the patient. based on the signs and symptoms.
on history and physical exam.
Present an

appropriate management plan.

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General Data
PC, a forty five year old female residing at Purok Chavez, Barangay Balide, Aurora, ZDS, has a chief complaint of yellowing of the skin.

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General Data
Status: Married Religion: Roman Catholic Nationality: Filipino Source of information and Reliability: 8/28/12

HISTORY
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History:
6 months prior to consultation
Onset of fever Onset of fatigue Onset of joint pain Onset of loss of appetite

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History:
3 months prior to consultation
Onset of sclera to be dark yellow in color On and off fever Fatigue, Joint pain and loss of appetite

persisted

(Patient cant deduce from memory previous

contact with the blood, semen, vaginal fluids, and other body fluids of someone who already 8/28/12 has a hepatitis B infection.)

Past medical history:

Medical:

2009:

Allergies: No

known allergies

admitted to a hospital in Iligan due to anemia

P Surgical: No history

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Family History:
Family history of asthma

No known familial histories: diabetes mellitus hypertension tuberculosis anemia cancer

allergy heart or kidney diseases congenital diseases mental illness
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OB History:
P G3P3 (2-1-0-3); all children were home

delivered via NSVD by a hilot.

P No pregnancy complications were observed. P She had her menarche at the age of 14 years

old.

P Her menstrual period is regular, with a

duration of 2-3days; variable amount of menses; consumes 3 pads per day.

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Family History:
The patient has a family history of

bronchial asthma in her paternal side. No family history of hypertension, stroke, tuberculosis, heart or kidney disease, epilepsy, any form of cancer and mental illness.

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Personal and Social History:

The patient is a self-employed farmer. She usually accomplishes household chores daily and farming vegetables.

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Personal and Social History:

Diet: vegetables, rice, and dried fish.

Tobacco: She is a non-smoker

Alcohol/drugs: non-alcohol drinker

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REVIEW OF SYSTEM
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General: No weight changes, fever, fatigue, weakness, or orthopnea Skin: No pallor, cyanosis, yellowish or any discoloration. No lesions, rashes, itchiness or other changes

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Head, Eyes, Ears, Nose, Throat (HEENT):

Head: No history of head injury, headache

or dizziness

Eye: No pain, redness, excessive tearing or

blurring of vision

Ear: No discharges, earaches, hearing loss Nose, sinuses: No nasal discharges, pain

or nosebleed
Throat: No pain, bleeding gums, sore

throat
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Neck: No stiffness or pain Respiratory: No cough, pain, cough or dyspnea Cardiovascular: No palpitation, pain or discomfort. (+) easy fatigability Gastrointestinal:
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Urinary and Genital: Increased frequency of urination, (+) dysuria, no hematuria, no discharge or sores (-) flank pain Musculoskeletal: (-) muscle weakness, (+) joint pain, (-) back pain Neurologic: No fainting, seizures, numbness or 8/28/12 loss of sensation

Hematologic: No easy bruising or bleeding Endocrine: No excessive sweating, no heat and cold intolerance, increased thirst Psychiatry: No history of depression, psychiatric disorder or mood changes
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PHYSICAL EXAMINATION
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PC is alert, conscious, and cooperative; responds subsequently to questions; she looks worried, and fatigued. Vital Signs:
Temperature: Heart Rate:

37.3 C taken at the axilla 97 beats per minute 130/80 mmHg

Respiratory Rate: 17 breaths per minute Blood Pressure: Weight: Height:

-------

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Skin:
Forearm is warm to touch; no pallor noted in both palm; nails without clubbing and cyanosis; no rashes visible. Generalized jaundice is evident.

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Head, Eyes, Ears, Nose, Throat (HEENT):

Head: Hair of average texture. Scalp without

lesions, normocephalic/atraumatic (NC/AT).

Eye: Both left and right conjuntivas are slightly

yellowish in color. Both scleras are jaundiced. Pupils equally round and reactive to light. Extra ocular movements intact lesions, areas of tenderness, discharge or swelling. Acuity good to whispered voice;

Ear: Symmetrical auricles. No gross deformity,

Nose: Symmetric, mucosa slightly yellowish-

pink, and septum midline. No gross deformities, nasal obstruction, congestion, exudates or inflammation. No tenderness on8/28/12 maxillary frontal sinuses.

Neck: Symmetrical supple neck without lesions or mass. Trachea midline. Multiple cervical lymphadenopathies. Thyroid not enlarged. Chest and Lungs: No chest retraction or use of accessory muscles upon breathing. Symmetric chest expansion. No tenderness or masses. Equal tactile fremitus, resonant and clear 8/28/12 breath sounds on both lung fields.

Cardiovascular: Regular rate and rhythm; no murmurs, PMI on 5th ICS Left midclavicular line Abdomen: Flat, , soft, symmetric abdomen. No scars, striae or discolorations. Normoactive bowel sounds. No abdominal masses. (+) tenderness noted at the RUQ.
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Extremities: Full and equal peripheral pulses. Calves supple, non tender. No inflammation or edema. No clubbing. Capillary refill time < 2 seconds.

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Peripheral Vascular: No pigmentation or ulcers. Musculoskeletal: No edema, cyanosis, varicosities on all extremities. Neurologic: Mental Status: Alert and cooperative. Thought coherent. Oriented to person, place, and time. 8/28/12

Cranial nerves I: not assessed II: pupils are equally brisk to light;

diameter of 2-3mm
III/IV/VI: V: VII:

normal

(+) corneal reflexes facial symmetry

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VIII: able to hear finger rustling

bilaterally IX/X: normal gag reflex

XI:

able to turn head from side to side; symmetrical in movement no atrophy; tongue is able to move cheeks against resistance;

XII:

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CLINICAL IMPRESSION
Acute Hepatitis B
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SALIENT FEATURES: History

Positive fever Fatigue Joint pain Loss of appetite

Physical examination
P Jaundice seen in skin, bilateral sclera,

conjunctiva, oral mucosa and hard palate. 8/28/12

DIFFERENTIAL DIAGNOSIS
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Differentia ls
Hepatits D

Rule in
Fatigue Loss of appetite Fever

Rule out

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Differentia ls
Hepatits A

Rule in
Jaundice Fever Loss of appetite

Rule out
(-) Dark urine

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Differenti als
Hepatitis C

Rule in
Jaundice Fever Loss of appetite

Rule out
Incubation period

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LABORATORY WORK-UP
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 Hepatitis profile

(serology)
CBC, PT, Blood C/S Urinalysis SGPT, SGOT

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MANAGEMENT
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P Refer to Rural Health Unit for further

evaluation and medical management.

P Supportive treatment:

Restricted physical activity

Avoid hepatotoxic drugs, contact precautions

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P Specific therapy:

Consider interferon for chronic hepatitis B and C Lamividine for chronic hepa B given at 100 mg 1 tab per year
Prophylaxis: hepatitis vaccination series

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Case Discussion
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Contact with infected person / needle/ body

Shortly after, the virus enters the new host

Initial response of virus is to infect liver cells

(hepatocytes)

Viral antigens bind to hepatocyte receptors

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Induces viral entry by receptor mediated endocytosis and uncoats In the cytoplasm Liver is affected/infected hepatitis Signs and symptoms: Fever, loss of appetite, myalgia, nausea, vomiting, fatigability, RUQ, and epigastric pain.
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