Viral Hepatitis Patient Case Presentation
Ms. T.J. is a 32-year white female and was recently seen in the urgent care center two weeks ago for feeling fatigue with nausea and vomiting. She was diagnosed with viral gastroenteritis. She received intravenous hydration and Zofran 4 mg IV once, then discharge on the same antiemetic Zofran 4 mg orally every 6 hours as needed times 4 days and advised to follow up with her primary care physician (PCP) if symptoms continue. Approximately three weeks later, T.J. was seen by her PCP for low grade fevers, recurrence of nausea, vomiting, weight loss, malaise, alterations in her taste and pruritus. She states that she has noticed that her urine is a dark color than usual and her skin is looking yellowish but not like a tan. She has intermittent right upper quadrant pain and tenderness while laying on her stomach.
Past medical & surgical history
- Diabetes diagnosed at age 15 years
- ORIF to left leg related to motor vehicle accident at age 19
- At age 20 continued chronic back pain secondary to motor vehicle accident
- Insulin pump placement at age 25
- Hypertension diagnosed at age 26
- History of opiate and IV drug abuse with multiple recurrence since age 19
- Viral gastroenteritis at age 32
Pertinent family history
- Mother alive and healthy at age 59 years
- Father alive with diabetes and hypertension at age 61 years
- Sister alive and well at age 29 years
- Maternal grandmother with history of hypertension (deceased)
- Maternal grandfather with history of lung cancer and cirrhosis of liver (deceased)
- Paternal grandmother history of dementia and diabetes (alive)
- Paternal grandfather history unknown
Pertinent social history
- One pack per day cigarettes smoker
- States is only social drinker with 4-6 drinks per occasion once per week
- Hobbies singing, dancing, painting
- Unemployed on disability
- Multiple sex partners