Hepatitis

Chief complaints: “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.” HPI: 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. PMH: MVA in 1996 that required a blood transfusion Cholecystitis and cholecystectomy seven years ago FH: Mother was alcoholic; died of car accident Father, 77, living with type II DM Two younger siblings are alive and well SH: 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 ROS: (+) 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 Meds: None Allergies: NKDA 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 Lab tests 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 UA Color Dark yellow Protein (-) Bacteria (-) Appearance Clear WBC 1/HPF Bilirubin (+) Ph 5.5 RBC (-) Ketones (-) SG 1.020 Nitrite (-) Glucose (-) Serology testing 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 Macrovesicular steatosis 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?