A 25 years female presents with repeated vomiting and several episodes of low grade fever. On examination, she was icteric and had right upper quadrant pain. She also gives history of recently returning from the area where she had poor hygienic and sanitary conditions. What is the most likely diagnosis?

1. A

   Osteomyelitis

2. B

   Enteric fever

3. C

   Hepatitis A infection

4. D

   Tuberculosis

Appeared in: BHU NO-2019

Explanation

• Hepatitis A is transmitted via the fecal-oral route, which aligns perfectly with the patient's history of visiting an area with poor hygienic and sanitary conditions.
• The clinical progression from non-specific symptoms like low-grade fever and vomiting (prodromal phase) to jaundice and right upper quadrant pain (icteric phase) is the classic presentation of acute Hepatitis A infection.
• The right upper quadrant pain is a direct result of liver inflammation (hepatitis), which causes the organ to swell and stretch its surrounding capsule.
• The incubation period for Hepatitis A is typically 2 to 6 weeks, consistent with an illness developing after 'recently returning' from travel.

Why Other Options Were Wrong

• Option A: Osteomyelitis is an infection of the bone. It presents with localized bone pain, fever, and swelling, but it does not cause jaundice or pain in the right upper quadrant of the abdomen.
• Option B: Although Enteric (Typhoid) fever is also transmitted via the fecal-oral route, its classic presentation is a high-grade, 'step-ladder' fever, abdominal rose spots, and relative bradycardia. Prominent early jaundice and RUQ pain are not typical features.
• Option D: Tuberculosis (TB) is typically a chronic infection, most commonly affecting the lungs, with symptoms like a persistent cough, weight loss, and night sweats. It does not fit this patient's acute presentation of fever, vomiting, and jaundice.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Differential diagnosis of acute febrile illness with jaundice based on clinical presentation and exposure history to guide bedside assessment, documentation, and the next nursing action.
• Nurses play a crucial role in preventing the spread of Hepatitis A by implementing strict contact precautions, especially with fecal matter, and educating patients and families about rigorous hand hygiene.
• Patient education is a key nursing intervention, focusing on safe food and water practices, the importance of handwashing, and advising on vaccination for household contacts and future travel to endemic areas.
• Hepatitis A is a notifiable disease. Nurses must ensure the case is reported to public health authorities to enable contact tracing and prevent wider outbreaks.

How to Approach the Question

• First, identify the key elements of the clinical scenario: a young female with fever, vomiting, jaundice, and RUQ pain.
• Next, note the most critical piece of history: recent travel to a region with poor sanitation. This strongly points towards an infectious disease acquired through the fecal-oral route.
• Evaluate the options in light of this transmission route. Hepatitis A and Enteric fever are transmitted this way, making them stronger possibilities than Osteomyelitis or Tuberculosis.
• Differentiate between the most likely options. Compare the patient's specific symptoms (low-grade fever, prominent jaundice, RUQ pain) with the classic presentations of Hepatitis A and Enteric fever. The symptoms align much more closely with Hepatitis A.
• Conclude that the constellation of symptoms and the exposure history make Hepatitis A the most probable diagnosis.

Concept Tested & Keywords

• Concept Tested: Differential diagnosis of acute febrile illness with jaundice based on clinical presentation and exposure history.
• Stem keywords: repeated vomiting, low grade fever, icteric, right upper quadrant pain, poor hygienic and sanitary conditions
• Lead-in keywords: most likely diagnosis
• Clinical cues: History of travel to an area with poor sanitation strongly suggests a fecal-oral route of transmission.
• Clinical cues: The combination of jaundice (icterus) and right upper quadrant pain points directly to acute liver pathology.

Question ID

Q4brHWi_VJFbfgJVTcwEZg

Copy ID

Reference Book

E6 Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Part 2 — Subpart A (pp 1-275 of 550) p. 34-36

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 244-246

E6 Microbiology OneStop Sastry p. 99-101