Case Study #3
Patient’s 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 laparoscopic 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, 7 years ago
FH
No known family history of liver disease, Mother was alcoholic; died 8 years ago in car accident, Father, age 77, has type 2 DM, Two younger siblings are alive and well
SH
• Divorced, but re-married 3 years ago
• Has 5 children from first marriage (three are still living at home)
• No tobacco use
• Drinks a 6-pack of beer on weekends
• Minimal caffeine consumption
• Has been employed as an information technology consultant at the university in town for
the past 11 years
• Has a significant history of IV drug use and cocaine snorting as a young adult but has “been clean now for 15 years”
• Denies any recent international travel
• Exercises daily (jogging and golf in summer, bowling and basketball in winter)
• Denies knowledge of having unprotected sex or living with anyone diagnosed with viral hepatitis
ROS
• (+) progressive fatigue and weakness
• (+) slightly elevated liver enzymes during last physical examination 10 months ago; was advised to seek follow-up at the liver clinic—which he failed to do, because he “felt fine”
• (+) yellowing of the skin/sclera; bleeding and bruising; swelling; gynecomastia; decrease in sexual drive; impotence; palmar erythema; spider veins; high blood pressure; rash or other type of skin lesion; itching; loss of appetite; changes in bowel or bladder function; and changes in stool or urine color
Meds: None
Allergy: No known drug or food allergies
PE and Lab Tests
Gen: WDWN muscular, white male in NAD, Wears glasses, Patient is friendly, soft-spoken, and cooperative and appears to be his stated age, He appears to be of ideal body weight
VS
Skin; Warm and dry with normal color and turgor, (+) obvious icterus, spider angiomata, palmar erythema, and other types of rash or skin lesions, (+) large tattoos on both forearms, lower legs, and lower back
HEENT: NC/AT, Pupils equal at 3 mm with normal response to light, EOMI, Clear sclera, (-) nystagmus and conjunctivitis, Funduscopic exam normal, TMs WNL bilaterally, Good dentition, Oral mucosa pink and moist with no lesions
Neck/LN:, Neck supple, (-) cervical, supraclavicular, and axillary lymphadenopathy, (-) thyromegaly, carotid bruits, masses, and JVD
Lungs/Chest/Back: CTA & P bilaterally, Mild scoliosis noted
Cardiac: RRR, S1 and S2 normal, (-) S3, S4, rubs, murmurs, and gallops
Abd: Soft and non-distended, Moderate hepatomegaly and tenderness in RUQ with light palpation, (-) splenomegaly, ascites, masses, and bruits, (+) BS
Genit/Rect: (-) masses, prostate enlargement, hemorrhoids, melena, and testicular atrophy, Normal anal sphincter tone
MS/Ext: (-) CCE, Peripheral pulses 2+ throughout and without bruits, Normal ROM
Neuro: A&Ox3, CNs II–XII intact, DTRs 2 throughout, (-) focal deficits , Toes downgoing, Sensation, coordination, and gait normal, Muscle strength 5/5 in all four extremities, Capillary refill normal at < 2 secs
Laboratory Blood Test Results
Urinalysis
Serology Testing
Liver Biopsy: Lymphocyte aggregates and some macrophages within portal tracts, Mild periportal fibrosis, Macrovesicular steatosis, All pathologic findings consistent with chronic hepatitis
Questions
Question 1. What is an appropriate diagnosis of this patient’s condition?
Question 2. Identify this patient’s potential risk factors for viral hepatitis.
Question 3. Why was serum AFP assayed in this patient?
Question 4. What is the single most significant abnormal finding in the patient’s urine and why is this finding consistent with the patient’s condition?
Question 5. Why is it critical that this patient refrain from further use of alcohol?