CASE 1

CHIEF COMPLAINT:  My eyes are yellow" for two days.

HISTORY OF PRESENT ILLNESS: Mrs. Salco is a 36 year old unemployed attorney who presents with yellow discoloration of her eyes which she noticed two days ago while washing her face. At first she thought the color was due to the lighting in her bathroom, but this morning, when going outside of her house to retrieve the mail, she thought her hands "looked yellow."

Mrs. Salco further admits to feeling "sick and tired" for the past 2‑3 weeks. She has lost her appetite and feels weak. During this time she has been frequently nauseated and ate very little food. Last night she developed a fever and "shook all over with a chill." This morning she awoke after a restless night with pain and a sensation of fullness in the right upper abdomen. She also vomited twice. The emesis was non‑bloody. She has not had diarrhea. She has no back or shoulder pain. She thinks she lost 20 lbs. during the last 3 months. She denies having joint pain or skin rash.

Mrs. Salco is a chronic alcoholic who has been hospitalized on several occasions for alcohol related problems, including a psychiatric admission. Although she was considered a gifted, young attorney with a bright future. since graduation from law school she has had many alcohol related work problems and lost her position at a prestigious firm three weeks ago. Since that time she has consumed approximately one fifth of vodka every day or so.

She is estranged from her husband but is having an affair with a man who uses IV drugs and has a history of hepatitis. She states she does not use IV drugs. She takes Tylenol for frequent headaches but takes no other medications. She smokes one pack of cigarettes per day. She had a spontaneous abortion at age 28 which required hospitalization but she can't remember if she had a blood transfusion. Last year she went to Mexico with her boyfriend.

PHYSICAL EXAMINATION: The patient is alert but haggard looking. She is skinny and shows prominent cheek bones. Her clothing is disheveled and her hair is uncombed. She appears much older than her stated age. Vital signs: Blood pressure in right arm 104/60 mmHg, Heart Rate 110/minute and regular, Respiratory Rate 18/minute, Temperature 38.9⁰ C.

HEENT: Bilateral, deep conjunctival icterus.

CHEST: Prominent ribs. Lungs are clear to percussion and auscultation.

CARDIOVASCULAR: Soft S₁ and S₂. No murmurs or extra cardiac sounds. 

ABDOMEN: The abdomen is round and slightly tympanitic. The liver is palpable beneath the costal margin (9 cm.) and tender. The liver span is 20 cm. There is no rebound tenderness, shifting dullness or splenomegaly. Normal bowel sounds.

SKIN: Icteric; spider nevi noted on shoulders.

EXTREMITIES: Bilateral tremors of hands; bilateral palmar erythema.

LABORATORY DATA:

1. Complete blood cell count.

·         White blood cell count: 17,000 cells/mm³ with modest shift to left

·         Hemoglobin 10.6 g/dL; Hematocrit 33%

·         Platelets 120,000/mm³  

·         MCV 110/micro m³  

            2. Chemistries: 

·         Aspartate arninotransferase (AST) 150 U/L

·    Alanine aminotrasferase (ALT) 60 U/L

·         Total Bilirubin 22 mg/dL

·      Alkaline phosphatase 400 U/L 

            3.  Prothrombin time 13.2 seconds

            4.  During, hospitalization WBC rose to 42,000/mm³; total bilirubin rose to

                32 mg/dL.