C AS E P R E S E NT A T I O N

ON
VIR A L H E P AT I T I S - A
Y – A R P I T CH O P R A
PREPARED B
F N U R S I NG , J A M IA
FAI D A COL LE GE O
RU Y EAR
(H ) N UR S I N G I I
HAMDARD B.SC.
. R A J LA X M I M A ’ A M
UB M IT T ED TO – MRS
S
 PATIENT’S CASE
SECTION – I
IDENTIFICATION DATA
NAME – MR. KUMAR
AGE – 18 YEARS
SEX – MALE
RELIGION – HINDU
ADDRESS – VASANT VIHAR, WEST DELHI
FATHER EDUCATION – 4TH CLASS
MOTHER’S EDUCATION – NA
FATHER’S OCCUPATION - SELF EMPLOYED
MOTHER’S OCCUPATION - HOUSE WIFE
WARD / BED NO. – GENERAL MEDICINE WARD / BED NO. 10
COMPLAINTS – FEVER WITH CHILLS, SINCE 3 DAYS WITH ABD. PAIN, COUGH &
INCREASED THIRST
YELLOWISH DISCOLORATION OF EYES SINCE 3 DAYS AND DARK COLORED URINE SINCE 4
DAYS.
DIAGNOSIS (PROVISIONAL) – VIRAL HEPATITIS??
DATE OF ADMISSION – 13/12/2020
SECTION – II
HISTORY OF ILLNESS
PAST MEDICAL & SURGICAL HISTORY - NOTHING SIGNIFICANT
FAMILY HISTORY – N.A.
SOCIO – ECONOMIC DATA – MIDDLE CLASS
PHYSICAL EXAMINATION –

• VITAL SIGNS – FEVER IS OFTEN PRESENT WITH A TEMPERATURE

UPTO 101⁰F
PULSE – TACHYCARDIA MAYBE PRESENT
BLOOD PRESSURE – HYPOTENSION MAYBE THERE
RESPIRATION – TACHYPNEA MAYBE PRESENT

• SKIN – JAUNDICE IS OFTEN PRESENT

PRURITIS AND RASH IS PRESENT
PETECHIAE MAY BE PRESENT

• EYES – ICTERIC SCLERA MAYBE PRESENT

• NECK – CERVICAL LYMPHADENOPATHY MAYBE PRESENT
• ABDOMEN – ABDOMINAL DISTENSION MAYBE PRESENT
ABDOMINAL TENDERNESS IS OFTEN PRESENT
HEPATOMEGALY WITH RIGHT UPPER QUADRANT TENDERNESS IS SEEN
SPLENOMEGALY MAYBE PRESENT
ASCITES MAYBE PRESENT IN LATER SERIOUS AND SERIOUS STAGES OF
THE DISEASE

• NEUROLOGICAL – ALTERED MENTAL STATUS

ENCEPHALOPATHY MAYBE PRESENT
 INVESTIGATIONS
Date Investigation Test report Normal Remarks
findings
14/12/2020 WBC 16000cells/ 4-11 Increased count
cumm shows signs of
infection
14/12/2020 Hemoglobin 11.1 g/dl 13-17 Low hemoglobin
levels
14/12/2020 ESR 40mm/1st hour 0-10 Inc. esr value is
a sign of
infection in the
body
14/12/2020 Total billirubin 24.4 mg/dl 0.1 – 1.2 Increased levels
shows liver
malfunctioning
14/12/2020 Gamma GT 94 1-55 High levels show
liver damage
14/12/2020 Serum Alkaline 143 IU 40-130 Inc. levels shows
phosphatase liver damage &
malfunctioning
 Date Investigation Test results Normal Remarks
findings
14/12/2020 Serum alt 646 IU 5-45 Inc. levels
shows liver
damage &
malfunctioning
14/12/2020 Serum ast 114 IU 5-35 Inc. levels
shows liver
damage &
malfunctioning
14/12/2020 Immunoglobin M Positive - Marker for liver
Antibodies Disease and
billiary cirrhosis
14/12/2020 Malarial parasite Negative - Plasmodium not
present(negativ
e)
14/12/2020 Widal test Negative - S. typhi.
Negative
14/12/2020 HIV 1 & 2 Negative - HIV negative

14/12/2020 HBsAG Non – reactive - Hep. B negative

HAV Positive - Hep. A positive

 Date Investigation Test results Normal Remarks
findings
14/12/2020 Complete Blood
Count
Hemoglobin - 11.1 g/dl 13 – 17 g/dl
14/12/2020 WBC 16000 4 – 11 cell/mcL Sign of infection
RBC 3.1 4.32 – 5.72 Exfreme low
M.cells/cumm Million cells/mcL count can lead
Platlets 1.5 L – 4.5 L to anemia
2.5 L/cumm Normal
14/12/2020 Total protein 7.0 g/dl 6 – 8.3 g/dl Normal
Albumin 3.6 g/dl 3.5 – 5.0 g/dl Normal
Globulin 3.4 g/dl 2 – 3.5 g/dl Normal
14/12/2020 Serum amylase 68 IU/L 30 – 110 U/L Normal

Prothrombin 18.2 11 – 13.5 sec Longer time for

time clotting also a
sign of liver
disease
14/12/2020 Na+ 139 mmol/l 135 – 145 Normal
K+ -5.4 mmol/l mmol/l Extremly
3.5 – 5.1 mmol/l Hypokalemic
Cl– 102 mmol/l Normal
•LEPTOSPIRA IGM & IGG – NEGATIVE
•USG ABDOMEN – SPLENOMEGALY , GALL
BLADDER WALL EDEMA

•FINAL DIAGNOSIS – BASED ON THE PATIENT’S

SUBJECTIVE AND OBJECTIVE DATA PATIENT IS
DIAGNOSED AS A CASE OF VIRAL HEPATITIS -
A.
MEDICATIONS
 INTRODUCTION TO VIRAL HEPATITIS
• VIRAL HEPATITIS IS A SYSTEMIC VIRAL INFECTION IN WHICH THERE’S
INFLAMMATION & NECROSIS OF LIVER CELLS & THUS PRODUCING A
CLUSTER OF CLINICAL, BIOCHEMICAL AND CELLULAR CHANGES.

• VIRAL HEPATITIS IS FURTHER CLASSIFIED INTO 5 MAJOR TYPES :-

1. Hepatitis -
A

3. Hepatitis - Hepatitis 2. Hepatitis -

C B

4. Hepatitis - 5. Hepatitis -
D E
 HEPATITIS - A
• HEPATITIS A WAS FORMERLY CALLED THE INFECTIOUS HEPATITIS
AND IS CAUSED BY RNA VIRUS OF THE ENTEROVIRUS FAMILY.

• IT IS PRIMARILY TRANSMITTED THROUGH THE ORO-FAECAL

ROUTE BY THE INGESTION OF FOODS AND LIQUIDS INFECTED
WITH THE VIRUS. THE VIRUS HAS ALSO BEEN FOUND IN THE
STOOL OF INFECTED PATIENTS EVEN BEFORE THE ONSET OF
SYMPTOMS AND DURING THE FIRST FEW DAYS OF ILLNESS.

• THE VIRUS IS TRANSMITTED VIA HAND TO MOUTH CONTACT,

INFECTED FOOD ITEMS.
 CONTINUED…
• AND ALSO BY NOT MAINTAINING PROPER HYGIENE OR IF
A PERSON IS LIVING IN UNHYGIENIC AREAS.

• HEPATITIS A VIRUS CAN ALSO BE TRANSMITTED

THROUGH SEXUAL CONTACT BUT IT IS MORE LIKELY
WITH ORAL-ANAL CONTACT AND ALSO DUE TO
INTERCOURSE WITH MULTIPLE PARTNERS

• IT’S NOT TRANSMITTED VIA BLOOD TRANSFUSIONS.

• THE INCUBATION PERIOD IS ESTIMATED
BETWEEN 2 TO 6 WEEKS AND THE DISEASE
LASTS FOR ABOUT 4 TO 8 WEEKS. MOST
PATIENTS RECOVER FROM THE INFECTION
AND IT RARELY PROGRESSES TO ACUTE LIVER
NECROSIS OR FULMINANT HEPATIC FAILURE
THAT ULTIMATELY LEADS TO LIVER CIRRHOSIS
AND DEATH. THE MORTALITY RATE IS JUST
0.5% FOR THE PEOPLE UNDER 40YEARS OF
AGE AND ABOUT 1 TO 2% FOR PEOPLE
ABOVE 40 YEARS OF AGE.
 PATHOPHYSIOLOGY
HAV INVADE INTO THE HUMAN BODY BY ORO-FECAL ROUTE AND
MULTIPLIES IN THE INTESTINAL EPITHELIUM & THEN REACHES
THE LIVER BY HEMATOGENOUS SPREAD. AFTER ONE WEEK THE
HAV REACH THE LIVER CELLS AND MULTIPLY THEN THEY MIX
WITH THE BILE AND ENTERS INTESTINE AND APPEAR IN THE
FACES. AFTER REPLICATION AND DISCHARGE OF THE THE HAV
THE LIVER CELLS STARTS TO DAMAGE. THEREAFTER THE
IMMUNE SYSTEM GETS ACTIVATED AND SECRETE GAMMA-IFN
THAT PROMOTES THE REPRESENTATION OF HUMAN LEUKOCYTE
ANTIGEN ON THE LIVER CELLS, CTL (CYTOTOXIC T-LYMPHOCYTE)
MAY THEN KILL THE TARGET CELL INFECTED WITH HAV.
 CLINICAL MANIFESTATIONS
1. MOST PATIENTS ARE ANICTERIC (WITHOUT JAUNDICE) AND ARE SYMPTOMLESS.
2. AND IN PATIENTS IN WHICH SYMPTOMS APPEAR ARE LIKE COMMON FLU LIKE & ARE MILD
DEVELOPING URTI AND MILD PYREXIA.
3. ANOREXIA
4. IN LATER STAGES THE PATIENT DEVELOPS JAUNDICE
5. EPIGASTRIC DISTRESS
6. HEARTBURN
7. NAUSEA AND VOMITING
8. ANOTHER SIGNIFICANT SYMPTOM OF HEP. A INFECTION IS THAT PATIENT TENDS TO
DEVELOP A STRONG AVERSION OF THE TASTE OF CIGARETTE / PRESENCE OF CIGARETTE
SMOKE IN THE ENVIRONMENT / OTHER STRONG ODORS.
DIAGNOSTIC EVALUATION
1. ABDOMINAL ULTRASOUND
2. HEPATITIS A SURFACE ANTIGEN (HAV) TEST FOR
THE CONFIRMATION OF PRESENCE OF VIRUS.
3. LIVER FUNCTION TEST FOR THE EXACT STATUS
OF THE FUNCTIONING OF THE LIVER AND ALSO
TO KNOW THAT UPTO HOW MUCH EXTENT THE
LIVER/LIVER CELLS HAS BEEN DAMAGED.
4. IGM ANTIBODIES LEVEL.
 COMPLICATIONS
• PROGRESSIVE HEPATIC ENCEPHALOPATHY CHARACTERIZED BY DROWSINESS AND
CEREBRAL EDEMA.

• GASTRO-INTESTINAL TRACT BLEEDING PROGRESSING TO STUPOR AND LATER COMA.

BLEEDING IS NOT RESPONSIVE TO PARENTERAL VITAMIN K ADMINISTRATION.

• EDEMA AND ASCITIS

• APLASTIC ANEMIA
• IN LATE COURSE OF THE DISEASE, LOSS OF CORNEAL AND PAPILLARY REFLEXES,
ELEVATED ARTERIAL BLOOD PRESSURE, RESPIRATORY FAILURE, TO
CEREBROVASCULAR COLLAPSE MAY BE PRESENT.
 PREVENTION
1. PERFORM HAND HYGIENE, USE SAFE WATER SUPPLIES AND KEEP A PROPER
CONTROL ON SEWAGE DISPOSAL.
2. PROPER VACCINATION SCHEDULE SHOULD BE IMPLEMENTED.
• A 2 DOSE VACCINE SHOULD BE GIVEN TO PEOPLE OLDER THAN 18 YEARS OF
AGE WITH A GAP OF 6 TO 12 MONTHS .

• CHILDREN AND ADOLESCENTS ARE GIVEN 2 ND

DOSE AFTER 1 MONTH AND 3RD
DOSE AFTER 6 TO 12 MONTHS.
• TWINRIX CAN ALSO BE GIVEN TO THE
PEOPLE ABOVE 18 YEARS OF AGE.

• PEOPLE WHO HAVEN’T BEEN

VACCINATED PREVIOUSLY, HAV CAN BE
PREVENTED IN THEM BY AN IM
ADMINISTRATION OF GLOBULIN DURING
THE INCUBATION PERIOD AS IT MAY
SUPPRESS THE OVERT SYMPTOMS OF
THE DISEASE AND WOULD PRODUCE
IMMUNITY AGAINST THE VIRUS.
 MEDICAL MANAGEMENT
• THERE’S NO SPECIFIC MEDICINE FOR THE TREATMENT OF PATIENTS WITH
HEPATITIS A INFECTION

• PROPER NUTRITIONAL DIET AND AVOIDING FATTY AND SPICY FOOD.

• BED REST
• IF ANOREXIA PREVAILS THE PATIENT SHOULD BE GIVEN SMALL SUPPLEMENTS
OR IF NECESSARY IV GLUCOSE CAN ALSO BE GIVEN.

• RESTRICTION OF PHYSICAL ACTIVITY.

 NURSING MANAGEMENT
• THE PATIENT MUST BE ISOLATED (ENTERIC ISOLATION).
• PATIENT SHOULD BE ENCOURAGED TO REST DURING ACUTE OR
SYMPTOMATIC PHASE.

• IMPROVE NUTRITIONAL STATUS.

• UTILIZE APPROPRIATE MEASURES TO MINIMIZE SPREAD OF THE DISEASE.
• OBSERVE THE PATIENT FOR MELENA AND CHECK STOOL FOR THE PRESENCE
OF BLOOD.

• PROVIDE OPTIMUM SKIN AND ORAL CARE.

 PATIENT EDUCATION
1. PROVIDE PATIENT WITH HEALTH EDUCATION RELATED TO PATIENT’S
DISEASE AND HIS/HER PRESENT CONDITION.
2. MAKING THE PATIENT UNDERSTAND THE RISK OF TRANSMISSION OF
HEPATITIS A TO OTHER HEALTHY FAMILY MEMBERS SO THAT THE PATIENT
AND FAMILY MEMBERS AFTER BEING DISCHARGED WOULD BE ABLE TO
TAKE ALL THE NECESSARY PRECAUTIONS.
 THANK YOU ALL FOR BEING A
PATIENT LISTENER AND VIEWER
AND WE HOPE THAT YOU ALL HAVE
GOT A BETTER UNDERSTANDING
ABOUT HEPATITIS – A INFECTION
AND IF ANYONE HAS ANY DOUBT
REGARDING THE CASE OR DISEASE
THEY MAY ASK.