Mrs. Jyoti, age 30, presented with fever, chills, nausea, vomiting, weakness, and yellowish urine for 8-10 days. Tests found hepatomegaly, ascites, pleural effusion, thickened gallbladder, edema, and anemia. She was diagnosed with Hepatitis A viral infection based on reactive HAV Ig G and negative Ig M. She received treatment including antibiotics, probiotics, ursodeoxycholic acid, pantoprazole, ondansetron, tramadol, and cetrizine. At discharge, she was prescribed ferrous ascorbate, folic acid, and calcium supplements and counseled on hypertension, liver health,

2. DEMOGRAPHIC DATA-
NAME- Mrs. Jyoti DOA- 6/1/20
AGE- 30 Years. DOD- 17/1/20
GENDER- Female
SUBJECTIVE DATA-
Presenting Complaint- C/O Fever
Chills
Nausea,vomit 8-10days.
Weakness
High Urine Colour
Recently Detected Hypertension.
OBJECTIVE DATA-
1. Yellowish Discolouration Of Urine.
2. Usg Borderline Hepatomegaly
3. Mild Ascities
4. Mild B/L Pleural Effusion
5. Gall Bladder(pseudowall Thick)
6. Pedal Edema
7. Anaemia.

3. Lab Parameter 6/1/20 7/1/20 8/1/20 9/1/20 10/1/20 11/1/20 17/1/20
VITAL SIGNS
BP (mmhg)
130/90mmh
g
140/90 130/80 130/80 120/90 120/90 110/80
PR (min)
RR (/min)
76
16
88 72 70 80 88 84
BLOOD TEST
Hb(g/dl)
RBC(mm/cu3)
Neutrophil(%)
11.8
3.14
- 71
TLC(/cumm3)
MCV(fl)
MCH(pg)
PLT(lakh)
10,100
1.10
24.4
77.9
99,000
LIVER FUNCTION
TEST
Billirubin(mg/dl)
Total
Direct
Indirect
0.2-1.O
0.1-0.3
10.06
6.30
4.36
SGOT(IU/L) 46
SGPT(IU/L)
S.PROTEIN
TOTAL
ALBUMIN
GLOBULIN
138
5.71
2.96
2.75
4.52
2.29
2.23
LDH(IU/L) 1121
URIC ACID(mg/dl) 7.73

4. SPECIALIZED DIAGNOSTIC TEST-
Malaria Test - Negative
Leptospira Rapid Test- Negative
HAV Ig G Ab- Reactive
Ig M- Negative
Hbs Ag- Negative
CONFIRMED DIAGNOSIS-
Hepatitis A Viral Infection.
PLAN-
Goasls Of Therapy-
1. To Eradicate Virus.
2. Keep Liver Healthy.
3. Normalize Liver Enzyme.
4. To Prevent Depelopment Of Complication.
5. To Prevent Relapse Of Disease.
6. Coordinate, Monitor, And Report On Implementation Of Viral Hepatitis Activities.
7. Prevent New Viral Hepatitis Infections.
8. Provide Education To Prevent Hepatitis A.

5. TREATMENT DURING HOSPITALIZATION-
Brand Name Generic
Name
Dose Frequenc
y
Start Date Stop Date Indication FDA category
Tab. Zocef Cefuroxime 500mg 1-0-1 9/1/20 13/1/20 Prophylaxic
antibiotic
C
Cap. Vibact Probiotic 2 capsule 1-0-1 9//1/20 14/1/20 Breakdown of
fat
-
Tab. Udiliv Ursodeoxycholi
c acid 300mg
300mg 1-0-1 9/1/20 15/1/20 Liver
Regenerration
B
Inj. PAN Pantoprazole 40mg IV 1-0-0 9/1/20 16/1/20 Antacid B
Inj Emset Ondansetron 4mg 1-1-1 9/1/20 11/1/20 Antiemetic B
Tab. Tramadol Tramadol HCL 100mg 1-0-0 9/1/20 15/1/20 Pain killer C
Tab. Cetrizine Cetrizine HCL
5mg/5ml
5mg 1-0-1 10/1/20 13/1/20 Itching B
Syp. Duphalac Lactulose
3.335g/5ml
275 1-0-1 10/1/20 12/1/20 Constipation B
Inj. METRO Metronidazole 500mg IV
12hr.
1-1-1 6/1/20 8/1/20 Prophylaxic
antibiotic
B

6. DISCHARGE MEDICATION-
DRUG RELATED PROBLEMS –
No Drps Are Found.
Brand name Generic
name
Dose Frequency Duration Indication
Tab.
Orofer XT
Ferrous
ascorbate
Folic acid
100mg
+
1.1mg
BD 1month Iron supplement
Tab. Supracal
OD
Calcium
citrate
Magnesium
Zinc
Vit D3
1000mg
+
100mg+
4mg+
200IU
OD 1month Calcium supplement

7. PATIENT COUNSELLING–
Disease,life Style –
Hypertension is increased blood pressure in your blood vessel,it occurs due to
stress,tension.
Liver Is Vital To The Body’s Metabolic Functions And Immune System. Without A Functioning
Liver, A Person Cannot Survive.
The Liver’s Position Is Mostly In The Right Upper Portion Of The Stomach.
Hepatitis A Is An Inflammatory Disease Of The Liver Caused By A Virus Called Hepatitis A.It
Can Be Transmitted To Others By Feco Oral Route & It Is Usually Self Limitary.
For Prevention
1. Maintain Hygiene.
2. Wash Hand Before Eating Food.
3. Exercise To Remove Stress .
4. Maintain Healthy Life Style.
Drug –
1. Orofer Xt- Oroferxt Can Be Taken Orally With Water, After Meals(it Maintain Hb
Level Given You As Iron Supplement)
2. Supracal- Take It After Food. (Given You For Increasing Bone Mineral Density
And Helps In The Formation And Maintenance Of Bones).
Do not take it together with orofer xt.

8. REFERENCE-
1. MICROMEDEX
2. https://Drugs.Bank.Ca/Drugs.
3. Antenatal Dexamethasone And Decreased Birth Weight
(Department of Obstetrics and Gynecology, University of Texas
SouthwesternMedicalCenter,Dallas,Texas,USA steven.bloom@email.swmed.edu).
4. Use Of Tramadol In Early Pregnancy And Congenital Malformation Risk
(Tornblad Institute, University of Lund, Lund, Sweden. Electronic address:
Bengt.Kallen@med.lu.se. et.al).
5. https://www.pregnancybirthbaby.org.au/vitamin-k-at-birth.
6. Investigation of Metronidazole Use during Pregnancy and Adverse Birth Outcomes.
(Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB
Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
et.al)
7. www.drug.com
8. GUIDELINES FOR VIRAL HEPATITIS SURVEILLANCE AND CASE
MANAGEMENT January 2005