KURSK STATE MEDICAL UNIVERSITY

RUSSIA

DEPARTMENT OF PEDIATRICS

CASE HISTORY

Patient – Ivanova Maria Ivanova

Age - 5 years old

Date of Admission – 16/10/2020

Diagnosis - Viral Infection, Hepatitis A complicated by liver failure.

Student - Manushee Kaushalya

Henadeera
Fifth Year, Tenth Semester
Group 26

ATTENDANT
CHIEF COMPLAINTS ON ADMISSION - The patient feels weak, with nausea,
pain in the abdomen, joint pain, pruritus, decrease in appetite. Seven days after the
beginning of the disease, the patient complained of jaundice, and reported a fever of 39
degrees Celsius.

COMPLAINTS ON EXAMINATION – Weakness, in a state of moderate severity,

abdominal pain, joint pain, pruritus. When an objective examination was carried out -
On objective examination dry skin, scratching and mild jaundice, marked diffuse icteric
sclera, visible telangiectasia on the hands, face, striae on the skin of the abdomen and
thighs were observed. The heart tones were dull, systolic murmur was heard at the apex.
The pulse was 100 beats per minute. In the lungs, breathing is vesicular. The frequency of
respiratory movements is 24 per minute. Abdomen was enlarged, the patient had palpation
painful, the liver size was + 4 cm, spleen was + 2cm.

PAST HISTORY

Mother’s health during pregnancy - The mother did not suffer from any health
issues during her pregnancy.

Course of the pregnancy – The course of the pregnancy was normal without any
associated complications.

Delivery, complications – No complications were present during the delivery.

Neonatal period

Gestational age – 39-40 weeks

Birth weight – 3300 grams
Birth length – 50 cm
Apgar Score – 8-9 points

Course of the neonatal period and its complications - Neonatal period was normal
growth with satisfactory conditions and free of any complications.
Feeding

Duration of breast feeding – Up to a year of breast feeding

Weaning, the age of its introduction, reasons of changes in schedule of its

introduction – Weaning introduced at 12 months, and carried out without changes.
Previous diseases

Children’s infections – Viral infection ( Upper Respiratory )

Upper respiratory viral infections (number per year) – One time per year

Bronchitis, pneumonia (frequency per year) - None

Intestinal infections – None

Food allergy (yes, no) - No

Drug allergy (yes, no) - No
Vaccination

Child is vaccinated up to age, up to individual schedule, reasons – The child has

received all vaccinations required at her age

Family history

Chronic diseases in child’s parents and close relatives – No history of chronic

diseases within the family, or amongst close relative

PRESENT ILLNESS

Manifestation of the disease and its’ duration by the moment of examination –

State of moderate severity, complains of weakness, pain in the abdomen, joint pain,
pruritus, jaundice.

Dynamics of the disease and symptoms – Dyspeptic syndrome, pain syndrome

Acutely ill. Fever up to 39 degrees Celsius. Jaundice – Cholestatic syndrome.
Objective examination – Dry skin, scratching, mild jaundice, diffuse icteric sclera,
telangiectasia on hands, and face. Stria present of the abdomen and thighs. Dull
heart tone, with systolic murmur at apex. Pulse – 100bpm. Vesicular breathing.

Previous therapy – No reports of previous therapy

 SYSTEM REVIEW
INSTRUCTION; Circle positive or abnormal responses and comment appropriately. Underline
negative or normal responses. Leave unaltered if information not available.

General - Weakness, fatigue, appetite, changes in weight, sleeping habits,

chills, fever, night sweats.

Integument - Color changes - Jaundice, pruritus, infections, tumor

(benign/malignant), hair changes, nail changes, skin disease, changes
in moles, rash, alopecia, pigmentation.

Eyes – Vision - Normal, date of last examination 16/10/2020,scotoma, pain,

diplopia, photophobia, glaucoma, refraction errors.

Ears - Tinnitus, hearing loss, discharge, other – Normal hearing

Nose, throat
and sinuses - Epistaxis, discharge, sinusitis, hoarsness, recurrent sore throat – No
impairments.

CNS - Headache, dirtiness, syncope, seizures, vertigo, diplopia, paralysis/paresis,

tremor, muscle weakness, ataxia, sensory abnormalities, head trauma,
history of meningitis, other – No pathology

Breasts - Masses, discharge, pain.

Urinary
Tract - Nocturia, frequency, urgency, dysuria, hematuria, difficulty in starting urinary
stream, urinary sueam abnormalities, incontinence, polyuria, renal
calculi, infections, flank pain, previous urine examination, previous
radiography of urinary tract - Dark coloured urine, visible
sedimentation.
Musculoskeletal
System - Joints: pain, swelling, heat, redness, stiffness, deformity, myalgias.

Psychiatry: hyperventilation, nervousness, depression, insomnia, nightmares,

memory loss, drug abuse.

PHYSICAL EXAMINATION
Vital Signs - Pulse 100 beats per minute, regular/irregular.

Respirations 24 per minute, regular/irregular.

Temperature (oral/rectal) Normal 36.7 degree Celsius

Blood Pressure 120/80 mmHg

Weight 17.9 kg Height 107.9 cm

General Inspection
Neurological- Appearance afect, motor behavior, memory, general attention span,
judgement, abstraction, delusions, hallucinations, mental state,
orientation to time, person, and place – Satisfactory general
condition, consciousness, well oriented in time and place, normal
mental state.
Level of
Consciousness - Alert, lethargic, obtunded, stuporous, semi-comatose, comatose.

Integument - Turgor, texture, pigmentation, cyanosis, telangectasia, petichiae,

purpura, ecchymosis, infection, lesions, hair, nails, mucous
membranes – Skin is dry, with mild jaundice, and pruritus.
Marked diffuse icteric sclera, visible telangiectasia on the hands,
face. Striae on the skin of the abdomen and thighs were observed.

Lymph
Nodes- Cervical, postauricular, supraclavicular, axillary, inguinal, other – Absent
enlargement.

Skull - Trauma, bruises, other – No trauma or bruises

Eyes - Lacrimal glands, cornea, lids, sclerae, conjunctivae, exophthalmos – Absent

any related pathologies.
Ears - Tophi, tympanic membranes, external canal, hearing, air conduction, bone
conduction -Absent pathological impairments

Mouth, nose
and throat - Dentition, gingiva, tongue, tonsils, pharynx, nasal mucosa, nasal
septum, sinuses – Icteric mucous membrane

Neck - Mobility, scars, masses, thyroid, salivary glands, tracheal shift

– Normal

Breasts - Masses, discharge, nipples, asymmetry, gynecomastia, skin – Normal

with no discharge

Joints and
Spine - Range of motion: fingers, wrist lbow, shoulder, hip, knee, ankle,
deformity, redness, heat, edema, tenderness – Arthralgia, impaired
range of motion

Chest
Respiratory rate: 24 /min.

Amplitude: shallow, deep, normal

Respiratory rhythm: regular, irregular, periodic, prolonged expiration - Tachypnea

Chest wall: deformities, excursion, good, fair, absent, use of accessory muscles –
No deformities

Comparative Percussion – Symmetrical resonant sound

Topographic – Anteriorly the apex of each lung rises about 3cm above the inner
third of the clavicle, the lower border of the lung crosses the sixth rib at the
midclavicular line, and the eight rib at the midaxillary line. Posteriorly, the
lower border of the lung lies at about the level of the T10 spinous process. On
inspiration, it descends further.

Line Right lung Left lung

Parasternal 5th interspaces -
Midclavicular 6th rib -
Anterior axillary 7th rib 7th rib
Mid axillary 8th rib 8th rib
Posterior axillary 9th rib 9th rib
Scapular 10th rib 10th rib
Paravertibral T 11- spinous process T 11- spinous process

Vocal fremitus - Normal

Auscultation: (diagram location of abnormal breath sounds, transmitted voice, or

abnormal percussion)

Vesicular sound present. Inspiratory longer than expiratory. Pitch and intensity of
expiratory sound is soft and low. Sound heard over both lungs.
Breath sounds: increased, decreased, normal, other.
Wheezes, rhonchi, crackles, rubs – Absent pathological sounds

Cardiovascular system

External jugular veins: distended / not distended ____________________________

Hepatojugular reflux – Absent

Carotid: thrill, bruit, upstroke – Absent

Precordium: active, quiet

Apex bit: location – Midclavicular line

characteristics – Moderate amplitude, strength and resistance

Heave (LV / RV), thrill (Systolic / Diastolic), location – Thrills not detected

Palpable ectopic pulsation - No

Percussion: heart dullness borders – Normal borders of the heart

Relative dullness Absolute dullness

1cm right to the right margin
Right border Left margin of the sternum
of the sternum
1.5cm medially from 2cm medially from
Apex
midclavicular line midclavicular line
Upper margin 3rd rib 4th rib
Vessel bundle: 4cm; Transverse diameter of heart 13cm.
Relative dullness absolute dullness right border1cm right to the right margin of the
sternum Left margin of the sternum Apex 1.5cm medially from midclavicular line2cm
 medially from midclavicular line Upper margin3rd rib4th rib
Vessel bundle: 4cm; Transverse diameter of heart 13cm.
Oliver-kardarelli symptom is absent.
Peripheral arteries pulsation was normal.
Radial arteries pulsation: it was in normal rate and rhythm and didn’t find any abnormal
properties.

Auscultation:

SI- louder than S2, heard after a long pause, low pitch, long duration, synchronous
with apex beat and carotid pulsation, no murmur.
S2 – S2 is louder than S1, heard after a short pause, high pitch, short duration,
asynchronous with apex beat and carotid artery, no murmur.
S3: (heard, not heard) __________________________________________________
S4: (heard/ not heard) _________________________________________________
Gallops ___________________________________________________________
Murmurs (systolic, diastolic, grade, location, radiation) – Systolic murmur heard
at apex
Clubbing, cyanosis, edema, thrombophlebitis, paradoxical pulse, stasis, ulceration -
Absent

Other ____________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________
Abdomen
Inspection: obesity, contour, scan, venous collaterals, hernias, pulsations, tenderness,
masses, rebound tenderness, rigidity, fluid wave, shifting dullness, frank ascites, bruits
– Striae on skin of abdomen

Tongue (color, coat, moist, dry) _______________________________________

Superficial palpation (tenderness, peritoneum irritation, muscular defence) –

Normal, no pathological changes

Deep palpation- Painful and presented tenderness during palpation

Stomach – Normal, no pathological changes

Intestine – Normal, no pathological changes

Liver:
Palpation - Painful
Size – Enlarged +4cm

Gall bladder – Palpable, normal shape, painful

Spleen – Enlarged + 2cm

Bowel Sounds: Normal, absent, hyperactive, hypoactive

Stool: frequency around once a day , character discolored stool

Urinary Tract
Palpation:
Suprapubical region – Normal, no pathological changes, painless
Lumbar region – Normal, no pathological changes, painless

Urination: frequency 3 times a day , character painless

Color of urine – Dark coloured urine

Genitalia – Normal, without any pathological changes

 PRIMARY DIAGNOSIS

Main disease – Acute Viral Hepatitis

Diagnosis is based on – Based on patient complains – weakness, dyspeptic syndrome,
jaundice, joint pain, fever.

Based on physical examination findings – Dry skin, diffuse icteric sclera, mild
jaundice, tachypnea, systolic murmurs present in the heart, telangiectasia on the hands
and face, striae present on the skin of abdomen and thighs. Enlarged liver and spleen.

Based on anamnesis vitae – Presence of a previous upper respiratory tract infection.

Based on laboratory investigations – Stool and urine analysis, changes present with
sedimentation, and disturbance is urobilinogen metabolism.

Accompany pathology – Mild jaundice, Acute liver failure

Complications – Hemolysis and aplastic anemia, Chronic hepatitis, Cirrhosis,

Cholestatic hepatitis, Chronic liver disease
 PLAN OF ADDITIONAL INVESTIGATIONS

Laboratory and Expected results Obtained data

instrumental methods
Common blood analysis L : (4-9 )×109/l, eos;( 0-5)%, stab: L 6.8×109/l, eos – 2%, stab – 4
(1-6)%, segm: (47-72) %, lymph: %, segm – 44 %, lymph – 46 %,
(20-42 )%, mono: (3-12)%, ESR (0- mono – 8%, ESR – 15 mm/h
22) mm/h

General urinary analysis S.G: (1010-1025)g/l, PRO: no, S.G – 1.018, PRO - no, GLU -
GLU: no, pH : 5, LEU : (0-6), - no, pH – 5, LEU – 1-2, UBG +
UBG: +

Total bilirubin – 160 mkmol/l,

Biochemical blood analysis Total bilirubin: (1,71-20,5) mkmol/l,
conjugated bilirubin: (6.47-17.1)
mkmol/l, ALT activity: (5-40) U,
АSТ activity: (7-56) U, thymol test:
(0-4) units,
Alkalinephosphatase:<120
conjugated bilirubin – 120
mkmol/l, ALT activity is 150 U,
АSТ activity is 130 U, thymol
test – 12 units, Alkaline
phosphatase 900

HBsAg (-), anti-HBc IgM (-),

ELISA test HBsAg (-), anti-HBc IgM (-), anti anti HBc IgG (-), anti-HDV IgM
(-), anti HCV (-), anti-HAV IgM
HBc IgG (-), anti-HDV IgM (-), anti
(+)
HCV (-), anti-HAV IgM (-)

The liver was enlarged; the

Ultrasound examination of parenchyma was diffusely
abdominal organs changed due to the small
structures of moderate
density. The portal vein was
7 mm in diameter. Splenic
vein in the gate area of the
spleen was 5 mm in
diameter. The gall bladder
was of regular shape,
hypotonic, in the cavity of
the visible sediment surface.
The tail of the pancreas was
edematous up to 26 mm,
echogenicity of the
parenchyma of the gland
was decreased
 CLINICAL DIAGNOSIS

Main disease – Viral Infection – Hepatitis A Virus, complicated by Acute Liver

Failure
Diagnosis is based on - Mostly due to findings during objective examination
followed by laboratory changes reviewed in ELISA test (anti-HAV IgM (+)).
Based on common blood analysis showing leukocytosis and lymphocytosis; In
biochemical blood analysis, liver damage is notice through elevated levels of AST, ALT,
conjugated bilirubin, alkaline phosphatase. Accompany with general urinary analysis
presenting high levels of urobilinogen that justify the color changes in the urine and stool.
The ultrasounds of the livers and the adjacent organs has shown findings running in
accordance to the clinical results.

Accompany pathology – Mild Jaundice

Complications - Acute or subacute hepatic necrosis, Chronic hepatitis, Liver Cirrhosis,

Hepatic failure,
 PLAN OF TREATMENT

Medicines Dosage Duration of the course

Acetaminophen (OTC)
10-15 mg/kg/dose PO q4-6hr
prn; not to exceed 15
mg/kg/dose or 1,000 mg/dose,
whichever is less or 75
mg/kg/day or 4,000 mg/day,
whichever is less.

Metoclopramide (Rx) 0.1-2 mg/kg IV q6-8hr PRN

Immune globulin IV (IGIV) 300-600 mg/kg IV q3-4wk

Gammaplex

Glucose infusion At least 4-6 mg/kg/min

N-acetyl cysteine, when

administered early, can
reduce liver damage and
hasten recovery in patients
with acetaminophen-induced
ALF.
 CLINICAL OBSERVATION

Date – 16/10/2020
Temperature – 36.8 C
Respiratory rate – 24 per min
Heart rate – 100 bpm
General state of the patient – Moderate severity
Dynamics of the disease since the last observation
Appetite – Decreased, but improving with course of treatment
Sleeping - Normal
Integument - Normal
Respiration – Tachypenic – Symmetrical on both lungs and vesicular breathing
is prominent in both lungs
Heart sounds – Normal S1, Normal S2 sounds. Absent pathological sounds
Abdomen – Normal, without pathology
Urination – Normal frequency, Normal colour and other characteristics
Stool - Normal

EPICRISIS

The 5 year old patient fell acutely ill with a fever of 39 degree Celsius. The patient
was admitted to the hospital on 16/10/2020. Upon admission the patient’s
complains were of weakness, nausea, abdominal pain, joint pain, with a decreased
appetite.
Jaundice appeared on the 7th day after onset of disease.

During the clinical examination the patient was in a state of moderate severity,
fever had decreased to normal, but the patient still had the complains made on
admission, along with pruritus. Objective examination identified dry skin, mild
jaundice, marked diffuse icteric sclera, visible telangiectasia of the hands, face, and
striae of skin on abdomen and thighs. The pulse was 100 bpm, with respiratory rate
being 24 per minute. Abdominal enlargement was noted, with painful palpation.
Liver +4cm, spleen +2cm, along with discolored stool, and dark urine. No other
pathologies were detected in other pathologies.

Laboratory tests were conducted, and markers were identified for Hepatitis A
infection ( ELISA – anti-HAV IgM (+), CBC, General urine analysis )
Signs of liver damage were identified also ( biochemical urine analysis, stool
analysis)
Other instrumental examinations revealed enlargement of liver, parenchyma
structure was changed. Edema of pancreas was noted.

The patient was had a normal birth, neonatal period, with no health problems with
the mother during pregnancy. The patient was vaccinated according to age.

Supportive therapy was used with pharmacological interventions.

Agents used include analgesics, antiemetics, vaccines, and immunoglobulins.
Prevention (either before or after exposure to HAV) is important.
Analgesic Agents: Acetaminophen reduces fever by acting directly on hypothalamic
heat-regulating centers, thereby increasing dissipation of body heat via vasodilation and
sweating. It relieves mild to moderate pain.
Antiemetic agents: Metoclopramide (Reglan, Metozolv), it’s used to treat nausea and
vomiting.
Immune globulin: Immune globulin IM (Gamunex, Octagam, Gammaplex) neutralizes
circulating virus. It is effective for pre-exposure protection and for post-exposure
protection when administered within 14 days of exposure. It should be used in place of
vaccination in those children too young (< 1 y) for vaccination when the child is
traveling to an endemic area.
The prognosis is positive for life and for health.