For Each Question, Please prepare answers for following Questions ?

Q.1: How will you approach the case ?

Case 1:

(R.No.1-15)

A 36 year old male came to the Outpatient Department for first antenatal check up of his wife who has a
positive urine pregnancy test checked by a pregnancy kit. She is a software engineer and her husband is
an architect by profession. During the antenatal check up various investigations were carried out. The
husband also got his routine investigations done along with his wife and was found to be hepatitis-B
positive. On obtaining a detailed history from the husband he gave a history of blood donation two
years back. Now he is worried about the health of his pregnant wife and their soon to be born child.
Q.1: How will you approach the case ?
Q.2 Please indicate Investigations if you want to order any additional tests.
Q.3: What can be the Diagnosis or discuss possible Differetial Diagnosis ?
Q.4 What Treatment you would like to give to the patient?

Case 2: (R.No.16-30)

A 19 year old girl, a medical student visits you with symptoms of nausea, and aversion to food since past
three days. She stays in a hostel, and feels that the food in hostel mess has led to indigestion. You take a
detailed history, and discover that she has gone on a college trip 15 days back where she indulged into
street food against the advice of her friends. Now she feels weak and lethargic. She has had normal
bowels, and her urine is darker than usual. On examination she appears to be icteric, and remaining
general and systemic examination is normal. You ask her to get a liver function tests done, and come
back in the evening.
She comes three days later, and this time she is accompanied by her hostel warden. Her eyes are
distinctly yellow now. She vomits in front of you, and her vomitus is clear watery material. Her
serum bilirubin done a day ago is 11.4 mg/dL (Conjugated 8.4 mg/dL), AST of 1348 IU/mL, ALT of
1750 IU/mL, ALP of 212 IU/mL. She appears more lethargic than earlier. You notice some reddish-
brown spots over her forearm.

Case 3: (R.No. 31-45.)

A 56 year old male presents in the emergency room, brought by his wife and his teenaged son. He is
disoriented, irritable, and is restless. His clothes are stained with vomitus. His wife, who works as a
housemaid, gives history that her husband was his usual self in the morning, when she had left home in
the morning. When she reached back in the evening, she noticed him lying in a pool of black colored
vomitus. She immediately called her son, and it took them two hours to reach the hospital. Wife gives
history that her husband was not going for work since past two weeks now. He had also started drinking
alcohol more than usual. On a usual day he would drink about two pouches of country liquor, but about
a week ago, after receiving his monthly salary, he started consuming a quarter of rum in addition. He
had also become more abusive in recent days. Since he would get up later in the day, and was not going
for work these days, his wife would leave cooked food at home for him to eat. Today, food was also left
untouched.

On examination you notice swelling over both feet, which pits on pressure. He also has a tense
distended abdomen, with an everted umbilicus. On dipping over left upper abdomen, a firm structure
hits back. You explain to wife and son of the patient, that he is critically ill, and it is quite likely that his
condition is related to alcohol intake. His wife responds by acknowledging that she was in a similar
situation three years ago, but her husband was saved after being in hospital for about ten days. She had
to mortgage her jewelry to meet hospital expenses then. “He was sober for about six months thereafter,
but then he started drinking again”, she said, and asked “will you be able to save him this time around ?”

Case 4:
(R.No. 46-60)

A 48-year-old woman has come for consultation as her USG abdomen showed presence of Grade 2 fatty
liver. She got the USG done as she was having intermittent episodes of fullness of abdomen, and heart-
burn after food. You obtained a detailed history and the patient denies any history of previous illness or
yellow eyes or alcohol intake. She has never had any swelling over the feet, or any bleeding or skin
lesions in the past, nor does she have any of these symptoms now. But she is a known diabetic on
medication and was taking glimepiride (2 tabs) and metformin hydrochloride (2 tabs) for diabetes. Her
height is 151 cm, body weight 110kg, and body mass index (BMI) 48. She was advised to get her liver
function test and blood glucose levels checked. Laboratory data disclosed the following values: Serum
bilirubin 1.5mg/dL (Conjugated fraction 0.70 mg/dL), AST 62 IU/l, ALT 70 IU/ml, ALP of 108IU/mL,
Serum albumin 4.2mg/dL, fasting blood sugar (FBS) 121 mg/dl, HbA1c 6.6% (4.3-5.8). She is the sole
earning member of the family and says that she cannot afford to be ill at this time.