Case Report D

(Laboratory interpretation report)

Name of clinician (student): _________________________________ Date: 2007 01 29.

Patient’s name: Billy Rubin.

A 25 year-old man, a sometime tattoo artist and night club bouncer, complains of
increasing malaise, anorexia and nausea for the last eight days or so. He had aching pains
in his knees, elbows and wrists.
The whites of his eyes are yellow

Additional information on request:

Temperature 38.6oC,
Some jaundice of skin.
Tender in right upper quadrant of abdomen,
Joints are not swollen

Medical history: 5 years ago fever with swollen lymph nodes (Epstein Barr virus?)

25 cigarettes a day
20-40 units of alcohol/week
Marijuana and ecstasy occasionally used. Over the past 2 years various tables and drug
mixtures at clubs. Not sure what is in them.
Denies IV drug use.
Homosexual contact but he says these are safely done.
Lives with three other people in an old apartment.
Family history – none.
Travel history – none.

Laboratory results and differential diagnosis:

Viral hepatitis
Differential Dx Test Result Healthy range Interpretation
Hepatitis PT 18 seconds 11-15 Acute viral
ALT 580 U/L 5-35 hepatitis
ALP 150 U/L 3-100
Bilirubin 55 umol/L 3-17
Glucose,fasting 4.2 mmol/L 4-6
Sodium 136 mmol/L 135-145
Potassium 3.5 mmol/L 3.5-5.0
Urea 3.2 mmol/L 3-7
Creatinine 65 umol/L 70-120
Haemoglobin 140 133-177
MCV 85 fL 81-100
Wbc 11 x 109/L 4-11 x 109/L
Platelet count 290 x 109/L 150-440x109/L
HAV IgG anti HAV Negative Negative No HAV
HBV HBsAg Positive Positive HBV
HCV HCV RNA Negative Negative No HCV
IgG antiHCV
Cytomegalovirus CMV antibody Positive Negative but * ?
Herpes simplex Immunoassays Not done
PCR
HIV associated HIV Negative Negative **
Drug induced Anabolic Not done ***
steroids

Underline the working diagnosis

Comments, qualifications:
Joint pain is more like hepatitis B.
* prevalence at age 30 between 40 and 100% of the population.
** was negative 6 months ago too.
*** possible user but not pursued. Cholestasis – no evidence for this.

Further diagnostic test(s) required and why.

LFT for chronic disease bilirubin, ALT, albumin, gamma globulins

Treatment:
Supportive.
Avoid alcohol, drugs, cigarettes.