viral hepatitis
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viral hepatitis is one of the chronic disease and can cured with proper treatment and care .Here is the case study on viral hepatitis for pharmacy students .
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viral hepatitis
- 2. SOAP FORMAT
- 3. Problem list • Fever since 7 days • Fatigue since 2 days • Weight loss 11 kg in one month • Not able to walk
- 4. 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
- 5. 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.
- 6. Objectives cont.. • Medication history : Glimipride and Metformin Hydrochloride 500 mg BD started since 25 days .
- 7. • 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-
- 8. Assessment • Diagnosis : on the basis of subjective and objective data patient suffering from viral hepatitis .
- 9. 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 .
- 10. 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
- 11. 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 .
- 12. Planning • The goals of therapy is to reduce liver inflammation and dissolve gallbladder stone . • To resolve patients complain .
- 13. Dietary Restriction Avoid eating banana ,custard apple and other sweet fruits. Avoid oily and spicy food Take orange juice .