Case Study 1
Scenario
P.M., 24-year-old house painter, too ill to work the past 3 days. Arrived at your outpatient clinic with his girlfriend, he seems alert but acutely ill, with an average build & a deep tan over the exposed areas of skin. He reports headaches, joint pain, a low-grade fever, cough, anorexia, & nausea and vomiting (N/V), especially after eating any fatty food.
P.M. describes vague abdominal pain that started about the same time as the other problems. He states that he has been using “a lot of Tylenol” for his pain. His past medical history reveals he has no health problems, is a nonsmoker, & drinks “a few” beers each evening to relax.
Vital signs are 128/84, 88, 26, 100.6 ° F (38.1 ° C); awake, alert, & oriented × 3; moves all extremities well with complaints of aching pain in his muscles; very slight scleral jaundice present; heart & lung sound clear & without adventitious sounds; bowel sounds clear throughout abdomen & pelvis; & abdomen soft & palpable without distinct masses. You note moderate hepatomegaly measured at the midclavicular line; liver edge is easily palpated & tender to palpation. P.M. mentions that his urine has been getting darker over the past 2 days.
- Your institution uses electronic charting. Based on the health history and assessment described in the scenario, which of the following systems would you mark as “abnormal” as you document your findings? Mark abnormal findings with an X and provide a brief narrative.
X Abnormal
☐ Neurologic:
☐ Respiratory:
☐ Cardiovascular:
☐ Gastrointestinal:
☐ Genitourinary:
☐ Musculoskeletal:
☐ Skin:
☐ Pain:
Case Study Progress
P.M. is manifesting key signs of hepatitis. Laboratory work is requested for identification of his precise problem.
- Which key diagnostic tests will determine exactly what type of hepatitis is present?
Laboratory Test Results
| Sodium
Potassium Chloride CO2 BUN Creatinine Platelets Indirect bilirubin Total bilirubin Albumin Total protein ALT AST LDH ALP PT/INR aPTT Urine urobilinogen Anti-HAV IgM HBsAg |
140 mEq/L
3.9 mEq/L 102 mEq/L 26 mEq/L 10 mg/dL 1.3mg/dL 210,000/mm3 1.6 mg/dL 2.3 mg/dL 3.8 g/dL 6.5 g/dL 66 units/L 52 units/L 245 units/L 176 units/L 12 sec/1.06 32 sec 1.6 IU/L Negative Negative Positive |
- Which of P.M.’s laboratory results specifically indicate liver disease?
- What is the difference between the hepatitis B surface antigen (HbsAg) and the hepatitis B surface antibody (HbsAb)?
- What factors in his history could have compounded the increased ALT levels?
- Considering the basic pathology of hepatitis, what type of diet will you strongly encourage P.M. to follow?
- For each characteristic below, identify whether it describes hepatitis A (A) or hepatitis B (B).
______a. Fecal-oral transmission.
______ b. Transmitted by sharing needles.
______ c. Transmitted by blood transfusions.
______ d. Vaccination is a three-shot series.
______ e. Illness is usually mild, similar to a flulike infection.
______ f. Symptoms include anorexia, nausea, vomiting, fever, fatigue, and jaundice.
- In P.M.’s case, the HbsAg is positive. This result indicates that P.M. is infected with hepatitis B and is in the acute period of the disease. Is this disease contagious? What precautions would you take while he is in the hospital?
- Pruritus is usually associated with jaundice. What will you do to ease this problem for P.M.? Name five interventions.
- How will you explain to P.M. the likely progression of his disease?
- P.M. is living at home with his parents and four younger siblings. The youngest is 4 years old. His parents ask how to prevent the rest of the family from getting hepatitis. What specific instructions will you give?
- How will you know that these instructions are understood?
- Given P.M.’s lifestyle, what specific patient teaching points must you emphasize?
Case Study Progress
P.M. is ready for discharge in a few days, & he confides to you that he feels so “guilty” about having hepatitis and endangering his girlfriend and family. He tells you he was at a party and did not think the one-time needle use could hurt him. He has lost his job because he is not able to go back to work & he hopes his family is not too afraid to have him return home.
- What action will you take?
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