Edison

Patient Identification: - Name: [Not specified] - Age: 19 years - Date of Birth: January 2, 2006 - Place of Origin: Chilon, Chiapas, Mexico - Blood Type: O Positive, Rh factor - Occupation: Undergraduate student in Education Family Medical History: Father, 50 years old, diagnosed with Type 2 Diabetes Mellitus, currently undergoing active treatment with Metformin. Non-pathological Personal History: - Lives in own home with access to basic public services. - Lives with a dog. - Reports a poor diet, primarily consuming street food. - Denies substance use and allergies. - Reports complete vaccination schedule. Pathological Personal History: - Denies chronic illnesses, trauma, blood transfusions, and previous surgeries. - Reports having had chickenpox at the age of 8. Sexual History: - Initiated sexual activity at age 16. - Has had 2 sexual partners. - Uses condoms as a contraceptive method. - Denies history of sexually transmitted infections. Presenting Complaint: The patient presented to the emergency department with general malaise and abdominal pain localized to the right upper quadrant (right hypochondrium). Associated symptoms include nausea. Reports an episode of fever two days prior (not quantified), which resolved with a single 500 mg dose of paracetamol. Vital Signs on Admission: - Heart Rate: 89 bpm - Respiratory Rate: 15 breaths/min - Blood Pressure: 120/90 mmHg - Temperature: 36.8°C - Weight: 53 kg - Height: 165 cm Physical Examination: - Patient is conscious and oriented to person, place, and time. - Mild jaundice observed. - Pupils equal, round, and reactive to light. - Nasal passages clear. - Ears with normal positioning. - Oral mucosa dehydrated. - Neck cylindrical, non-tender. - Chest with normal breath sounds bilaterally. - Abdominal tenderness noted; positive Chauffard’s and Mathieu’s signs. - Limbs intact and without abnormalities. Provisional Diagnosis: Probable Hepatitis A Laboratory and Imaging Findings: - Complete Blood Count: Leukocytosis (WBC: 18,000/mm³) - Liver Function Test: Elevated aminotransferases (AST/ALT: 700 IU/L) - Serology: IgM positive for Hepatitis A - Abdominal Ultrasound: Presence of hepatomegaly Prognosis: Favorable, with supportive and palliative care. Treatment Plan: Palliative management and oral rehydration therapy with increased fluid intake.