“I don’t really feel seriously sick, but my wife insisted that something is wrong and that I should see a doctor. I’ve been a bit tired and weak now for nearly three weeks. I’ve not been working more than usual, my appetite is good, and I’m only 52—so it can’t be old age setting in already. Also, and this may be nothing, but I’m a little sore under my right ribcage—not really pain, but it is uncomfortable when I jog.”
D.H is a 52 yo white male with no significant past medical history, except for a severe bout of cholecystitis seven years ago that resolved following laproscopic cholecystectomy. He states that he has been healthy until three weeks ago, when he noticed some fatigue and weakness. He does not recall a past history of liver problems.
MVA in 1996 that required a blood transfusion
Cholecystitis and cholecystectomy seven years ago
Mother was alcoholic; died of car accident
Father, 77, living with type II DM
Two younger siblings are alive and well
Drinks a 6 pack of beer on weekends
Denies tobacco use
Significant history of IV drug use and cocaine snorting as a young adult but “clean now for 15 years”
Denies recent travel
Employed as IT consultant, and married
(+) for fatigue and weakness
(+) slightly elevated liver enzymes during last physical 10 months ago, was advised to follow up at liver clinic which he failed to do because he “felt fine”
(-) yellowing of skin/sclera, bleeding and bruising, palmar erythema, spider veins, high blood pressure, rash or skin lesions, changes in bowel or bladder function, changes in stool or urine color
PE and lab tests:
Gen: white male in NAD
VS: T 98.3, HR 69, BP 138/80, R 16 unlabored, Ht 6”1, Wt 174 lbs
Skin: warm and dry no icterus, rash, spider angiomata or palma erythema
(+) large tattoos on both forearms, lower legs, and lower back
HEENT: PERRLA, clear sclera, (-) nystagmus, fundoscopic exam normal, TM WNL, oral mucosa pink and moist with no lesions
Neck: supple (-) lymphadenopathy (-) JVD, bruits, normal thyroid
Lungs: CTA bilaterally, mild scoliosis
CV: RRR no murmurs rubs or gallops
Abd: soft, non distended, moderate hepatomegaly and tenderness in RUQ with light palpation, (-) splenomegaly, ascites, bruits, masses; bowel sounds present
GU: normal rectal sphincter, no BPH, masses or hemorrhoids
MS/Ext: pulses 2 + throughout, normal ROM
Neuro: A and O X 3, CN intact, DTR 2 + throughout
Na 138 PMNs 51% Protein 5.6
K 3.8 Bands 3% PT 12.3 secs
CL 104 Lymphs 37% PTT 29.8 secs
HCO3 25 Monos 9% Ca 8.5
BUN 15 AST 142 Mg 2.0
Cr 1.0 ALT 120 Phos 3.9
Glucose 85 Alk Phos 178 Vit D 51
Hgb 14.1 Bili total 1.5 Vitamin A 19
Hct 40.1% Direct bili 1.1 Vitamin E 0.6
WBC 9.9 Bili indirect 0.4 AFP 14
Plt 263,000 Alb 3.0
Color Dark yellow Protein (-) Bacteria (-)
Appearance Clear WBC 1/HPF Bilirubin (+)
Ph 5.5 RBC (-) Ketones (-)
SG 1.020 Nitrite (-) Glucose (-)
IgG anti-HAV Ab (-) HCV RNA(2.7 mil copies) (+)
HBsAg (-) IgG anti-HDV Ab (-)
IgG anti-HBe Ag (-) IgG anti-HEV Ab (-)
IgG anti-HCV Ab (+) HCV genotype Type 1
Liver Biopsy results:
Lymphocyte aggregates and some macrophages within portal tracts
Mild periportal fibrosis
All pathologic findings consistent with chronic hepatitis
Questions: use 1 journal article as reference
1. What is an appropriate diagnosis of this patient’s condition?
2. Which three tests are most definitive in determining this diagnosis?
3. Identify this patient’s potential risk factors for hepatitis.
4. What is the most likely cause of this patient’s hepatitis?
5. What is the preferred treatment for this patient?
6. Why was serum AFP tested?
7. Why is the patient’s WBC differential consistent with viral hepatitis?
8. Identify at least 6 abnormal lab tests consistent with diagnosis of liver injury and reduced hepatic function.
9. Why is it critical that this patient refrain from further alcohol use?