Case Presentation
Viral Hepatitis

SOAP FORMAT

Problem list
• Fever since 7 days
• Fatigue since 2 days
• Weight loss 11 kg in one month
• Not able to walk

Subjective
• MRD no : 255392 ( bed no :16)
• D.O.A :15/12/2015
• Age: 51 years
• Weight 65 kg Height : 5’3” BMI :52
(OVERWEIGHT )
• Ward: Female Medical ( unit 2)
• Diagnosis: Viral Hepatitis

Objectives
• Social History: Educated and House wife living in
nuclear family having two children.
• Family History: Husband suffering from Diabetes
mellitus *8 years
Hypertension * 10 years
• General Appearance: Moderately built.
• Medical history : Diabetes diagnosed since 2
years and treated for fever two weeks before .
• Lost 11 kg in last 1 month.

Objectives cont..
• Medication history : Glimipride and
Metformin Hydrochloride 500 mg BD started
since 25 days .

• Abnormal Lab Parameters
Urea :15
RBS :254 mg/dl
T.Billi : 68
D.Billi : 4.0
AST : 862
Alt : 820
WBC : 11700
Platelets : 4.31 lacs/cmm
USG shows : Gallbladder stone and liver inflammation
P+I+C-C-L-E-

Assessment
• Diagnosis : on the basis of subjective and
objective data patient suffering from viral
hepatitis .

STANDARD TREATMENT
• No specific treatment is indicated, other than
supportive care that includes intravenous (IV)
rehydration
• Etiology :
Obesity is one of the biggest risk factors. Obesity
can cause a rise in cholesterol and can also keep
the gallbladder from emptying completely.
Age and Gender : women of older age are more
prone to get gall stones .

Assessment
Drug Name Dose Frequency Indication Days of therapy Complains
I.Ceftriaxone 1 gm BD 12 Hourly Noscomial
Infection
Day 1 Day 1 c/o
abdominal pain
,decreased
appetite
FBS :400 MG/DL
I. DNS 10 ml BD 12 Hourly Supplement
therpay
Day 1
I D 5% 10 ml BD 12 Hourly Supplement
therpay
Day 1
I Ranitidine 50 mg BD 8 Hourly H2 receptor
blocker
Day 1 Day 2 c/o fever
in noon and
evening and
itching
FBS :189 MG/DL
I.Ondancetro
n
50 mg BD 12 Hourly Antiemetics Day 1,2
T.MVBC BD 12 Hourly Supplement
therpay
Day 1,2,3
T.FA BD 12 Hourly Supplement
therpay
Day 1,2,3 Day 3 c/o itching
and fever at
night .FBS :97
MG/DLT.Acetaminop
hen
500 mg SOS Antipyrectic sos

Assessment
Drug Name Dose Frequency Indication Days of therapy
T.Udiliv
ursodesoxycholic
acid
150 mg TD Dissolution of
gall stone
Day 1,2,3
Syp lactulose 2 spoons TD Stool softener
and prevents
hepatic en
cepholepathy
Day 1,2,3
I.RL 10 ml BD 12 Hourly Supplement
therapy
Day 2,3
T.Glimipride and
metformin
hydrochloride
500 mg BD 12 Hourly Control on blood
sugar levels .
Day 1,2,3
T. Cetrizine 10mg 0-0-1 Control itching Day 3
Patient is taking I glass of custard apple leaves juice every day to control diabetes
Taking Dhanvantri tablets 3 times in a day .

Planning
• The goals of therapy is to reduce liver
inflammation and dissolve gallbladder stone .
• To resolve patients complain .

Dietary Restriction
Avoid eating banana ,custard apple and other
sweet fruits.
Avoid oily and spicy food
Take orange juice .