Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 35 year old female with abdominal pain of 3-4 days duration. She states she has had an uneasy feeling in her stomach for about 3-4 days, and two days ago her friend told her my eyes look yellow. The discomfort is in the upper part of the abdomen, but it isn’t very bad; she feels nauseated a lot. She has not had similar in the past. Eating does not seem to affect it, but she is not very hungry. It is not any worse at night, and TUMS or Prilosec OTC doesn’t help. She had a fever one day last week with achiness, and she vomited several times that day, but not since. No diarrhea, no constipation. She had a normal BM yesterday. No blood in stool, no dark stool, no light colored stool. For the past two days the whites of her eyes look yellow. LMP 2 weeks ago. No vaginal discharge. No chest pain, dyspnea, or cough. No recent trauma. No known gallstones. She doesn’t drink alcohol or use drugs. She takes naproxen or Tylenol a couple of times a year for a headache; She is on her feet a lot at work. She has not had a similar sensation in her upper abdomen before, and she has never visited a doctor before for this kind of problem. No steroid use. No smoking. No recent hospitalization. Only medication is estrogen-based oral contraceptive. Student at local university, and works part time as a waitress. Grew up in India, and spent the summer there; returned to the US 2 weeks ago to begin the fall semester.
Vital Signs: BP 110/70, P 88, R 16, T 37 C, O2 98% on RA
General: The patient is alert and oriented x3.
Skin: No rash. (No stigmata of liver disease. No jaundice. No bruising. No Cullen’s or Grey-Turner sign).
HEENT: PERRLA. EOMI. The sclera are jaundiced bilaterally. There is no conjunctival pallor. Ear canals and TM’s are normal. Pharynx is normal. Neck: supple. No lymphadenopathy
Abdominal: Tender to deep palpation in the epigastric region. Moderate tenderness to palpation in the RUQ. The liver edge is smooth, palpable 2FB below the right costal margin and is tender. Percusses to 9 cm. No LUQ, RLQ, LLQ, or suprapubic tenderness. No rebound. No guarding. No bruising or skin changes, no caput medusa,. No splenic enlargement. Normal bowel sounds.
Rectal: Brown stool. Hemoccult negative.
Genitourinary: Normal external genitalia. No vaginal discharge. No cervical discharge, no cervical motion tenderness, no mass.
Labs: Lipase – Negative, Urine Pregnancy Test – Negative, *CBC and differential – Normal
*Liver Enzymes – AST 632, ALT 874, Alkaline phosphatase 135, Total Bilirubin – 8.7
Hepatitis Panel – Hepatitis B surface antigen – Negative, Hepatitis B core antibody, IGM – Negative, Hepatitis A antibody, IGM – Positive, Hepatitis C antibody — Negative