Internal Medicine Learning Issues - example

Case example

41 y.o. Vietnamese Male presents with a couple weeks of yellow eyes, dark urine and several months of fatigue. Admits to taking Chinese Medicines and moderately heavy alcohol intake. A couple occasions experimented with IV heroin. Mother had Hep B and died of liver cancer. Was yellow prior to dying.

Examination revealed jaundice, spider angiomata on upper trunk and palpably enlarged liver.

Patient advised to reduce alcohol intake.

Bloods test reveal mild macrocytosis, mild thrombocytopenia, markedly elevated bilirubin, non-specific elevations of GGT and ALP and 4-5 x normal ALT and AST. Albumin mildly low. Hepatitis serology showed no acute infection and past EBV infection.

Ultrasound demonstrates heterogenous liver echotexture with enlargement.

Referred to specialist. Further tests show normal iron studies, caeruloplasmin and alpha 1 AT and aFP. ANA, LKM, SMA and AMA negative. HBeAg positive

LFTs improving after cessation of alcohol. Liver biopsy showed moderate to severe abnormality.

Patient chooses to have entecavir orally but not interferon intravenously and for monthly clinic followup

After several months, bloods test show viral load undetectable and normal ALT.

After one year, blood test show viral antibody response but lost to follow-up

Re-presents after several years because brother recently diagnosed with liver cancer. aFP now positive and ultrasound demonstrates 2.5cm focal lesion.

Learning Issues