Age:  49 years old
Sex: Female
Occupation: Rubber factory worker
Place: Bukit Terit, Muar

HISTORY:

Date : 21/06/2006

A)      CHIEF COMPLAINT:

-yellowish discoloration of both eye, face, skin, neck, and chest for 1 day.

     B)  HISTORY OF PRESENTING ILLNESS:

Yellowish discoloration of both eye, face, skin, neck, and chest for 1 day.
It was sudden in onset. The yellowish discoloration was gradually progressive,
associated with itching which was moderate, more over the chest and increases
on hot bath.   Patient passed pale colored stool and tea colored urine.
Patient doesn’t have diarrhea and any bone pain.
       Fever was insidious in onset, low grade, intermittent and no association with
chills and rigor.  Patient took 500mg of paracetamol twice daily but fever
didn’t subside.  Fever subsided yesterday and patient noticed she had
yellowish discoloration. Patient also complains of fatique, weakness and
lethargy.
       Abdominal pain lasted for 11 days.  Pain localizes at left, right
hypochondrium and umbilical area.  It was dull aching, no reffered or
radiation to shoulder and pain is associated with abdominal distention.  There
was no aggravating and relieving factor.  Patient also complains of unable to
breath well or cough when she had pain in abdomen.
       Nausea and vomiting lasted for 11 days.  There was 3 episode of vomiting
which was insidious in onset, contained undigested food particles, about half
a cup, non projectile, and non blood stained and not associated with abdominal
pain.  Patient also has loss of appetite and loss of weight of 3 kg.
       There is no history of drug intake, dyspnoea, chest pain, palpitation,
orthopnoea, paroxysmal nocturnal dyspnoea, pedal edema and syncope.







B)      PAST HISTORY:

No previous history of fever with jaundice, blood transfusion, injection and
needle sharing, traveling or intravenous drug abuse. No medical illnesses like
bronchial asthma, Hypertension, Diabetes Mellitus or Heart Disease.

C)       TREATMENT HISTORY:

Not on any medication.

D)      PERSONAL HISTORY:

On mixed diet, had loss of appetite and loss weight of 3kg, no sleep
disturbance, stool is pale in color, urine is tea colored.  Before fever and
jaundice patients bowel and bladder habit is normal.


E)      FAMILY HISTORY:

No similar history in the family and no other significant history.

F)      MENSTRUAL HISTORY:

Menses of 7 / 28 days of cycle and regular.  No dysmenorrhoea or passing of
clots.

G)      SOCIAL HISTORY:

A non smoke and non alcoholic.  Patient lives in village house with 4
occupants.  Her monthly income is RM 500.00 and patient pays for her medical
bill.

H)      PROVISIONAL DIAGNOSIS:

       Viral Jaundice

From the symptom and sign of fever, jaundice, tea colored urine, pale stool,
lethargy, loss of appetite and weight.


GENERAL EXAMINATION:

Patient is conscious, cooperative, moderately built and nourished.
There are rashes over her chest, icterus on both eye, face, neck and chest.
No pallor, clubbing, plapping tremor, spider naevi, palmar erythema, skin
excoriation, pedal edema and generalized lymphadenopathy.

Vital sign:

Pulse: 82 beat per min, normal volume, regular rhythm, all peripheral pulses
felt. No collapsing pulse and blood vessel thickening.
       Blood pressure:  130/70 mmHg on right arm supine position.
       Respiratory rate:  20 per min
       Temperature:  37.6° C

SYSTEMIC EXAMINATION:

Abdominal examination.

       Inspection:
               Abdomen is uniformly distended, flanks are full, umbilical is central and
inverted, no discoloration of skin or striae, all quadrant moves equally with
respiration.  There are no visible scars, sinus, dilated veins, pulsation and
mass. Hernial orifices are intact.

       Palpation:
               No local rise in temperature.
               On superficial palpation there is no tenderness, guarding and rigidity.
               On deep palpation there is presence of mass over the right hypochondrial
area.  Lower border of mass felt 4 cm from the costal margin in the right mid
clavicular line.  The mass has round edge, smooth surface, firm inconsistency,
and moves with respiration.  No tenderness and pulsation felt over the mass.
Getting over the mass is not possible, unable to insinuate fingers between
costal margin and mass.  There is no splenomegally and kidney is not palpable.

Percussion:
               Percussion over the liver: upper border felt at 5th intercostals space and
liver span is 17 cm.  There is no shifting dullness.  All other area of
abdomen is resonant.

       Auscultation:
               Normal bowel sound heard (2-3 per minutes) and there is no bruit.

OTHER SYSTEMS:

Cardiovascular system:
       S1 and S2 heard in all area of heart. No murmur.

Respiratory system:
       Normal vesicular breath sound in all area of lungs.  No adventitious sound
heard.



Central nervous system:
       Higher mental function is intact, motor, sensory system and cranial nerve is
normal.

DISCUSSION:

       A 49 years old Malay lady presents with fever, jaundice associated with
itching, pale stool, tea colored urine, loss of appetite and weight, vomiting
and abdominal pain.  On examination there is jaundice of skin and mucus
membranes, uniform distention of abdomen, hepatomegally with liver span of 17
cm.


PROVISIONAL DIAGNOSIS:  VIRAL HEPATITIS.