1. M G R Acute A viral hepatitis CASE 1 R2 이은정 / R4 박재현 / prof 김병호

2. History 10500259 고○선 (F/51) Adm> 2009.4.2 Chief Complaints 발열, 두통, 오심 o/s> 내원 보름전 Present illness 51 세 여환, 평소 특이병력 없던 자로 내원 보름 전부터 발열, 근육통, 두통 등의 증상 있었으며 내원 3 일전부터 증상 악화되고 오심, 구토 발생하여 입원함

3. Past Medical History DM (-) HTN (-) Hepatitis (-) Pulmonary Tb (-) Operation Hx (-) Personal History Alcohol (-) Smoking (-) Travel Hx (-) Medication Hx (-) Herbal medication Hx (-) Family History Unremarkable History

4. Review of System General Febrile sensation (+) Chill (+) Fatigue (+) Skin Rash (-) Itching (-) Jaundice (+) H&N Headache (+) Sore throat (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) G-I Anorexia (+) Nausea (+) Vomiting (+) Diarrhea (-) Constipation (-) Abdominal pain (-) Renal Dysuria (-) Frequency (-) Hematuria (-) Back & Ext Upper back pain (-) Lower back pain (-)

5. Physical Examination V/S 120/80mmHg – 88/min – 16/min – 38.5°C General Appearance Alert mentality Acutely ill looking appearance Head & Neck No cervical LN enlargement No neck vein engorgement Eye & ENT Isocoric pupil with PLR (++/++) Pinkish conjunctiva Icteric sclera Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound Tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Back & Ext. CVA tenderness (-/-) Pretibial pitting edema (-/-) Body weight :63.2 Kg Height : 150.6 cm BMI : 27.8

6. Initial Laboratory Findings CBC/DC 2,260 /mm 3 - 15.7 g/dL - 46.3% - 150,000 /mm 3 (Seg 64%) PT sec 15.6 PT INR 1.22 Chemistry TB / DB 2.95 / 2.14 mg/dL CRP 1.7 mg/dL Prot / Alb 6.8 / 4.2 g/dL Glucose 153 mg/dL AST / ALT 4640 / 4023 U/L LD / CK 9108 / 45 U/L ALP / GTT 165 / 297 U/L Cholesterol 136 mg/dL BUN / Cr 18 / 0.7 mg/dL Na / K / Cl 135 / 3.8 / 99 mmol/L U/A RBC 0~1 / HPF WBC 0~1 / HPF Bilirubin (++) Urobilinogen (+-)

7. Initial Chest X-ray

8. Initial EKG

9. #1. Acute hepatitis r/o Acute A viral hepatitis r/o Other viral hepatitis r/o Systemic viral disease r/o Alcoholic hepatitis r/o Toxic hepatitis Initial Problem List

10. Diagnostic & Therapeutic Plans Diagnostic plan Viral marker Abdominal sono Abdominal CT, if needed Therapeutic Plan Supportive care Symptomatic treatment

11. Viral marker Anti-HAV IgMpositive Anti-HBc IgGreactive Anti-HBs Abpositive HBs Agnon-reactive Anti-HCVnegative Anti-HIVnegative Anti-CMV IgMnegative HEV IgGnegative HEV IgMnegative Acute A viral hepatitis !!

12. Abdominal sono (2009.4.3)

13. Clinical course (09.4.2 ~ 09.5.3) Abdominal CT, Cryptogenic lab 시행

14. Abdominal CT (2009.4.21)

15. Cryptogenic lab ANANon-reactive C-ANCANegative P-ANCANegative RF (IU/ml)<9.50 Ceruloplasmin (mg/dl)30 Anti mitochondria AbNegative alpha 1 antitrypsin (mg/dl)148 All negative !!

16. Clinical course after discharge (09.4.2 ~ 09.5.29) 퇴원

17. CASE 2 CASE 2

18. History 11132094 이○영 (F/36) Adm> 2009.4.28 Chief Complaints 상복부 동통, 오심 o/s> 내원 4 일전 Present illness 36 세 여환, 평소 특이병력 없던 자로 내원 10 일전 발열로 약 복용 하였으나 증상 호전 없고 4 일전부터 상복부 동통, 오심 등 발생하여 응급실 경유 입원함

19. Past Medical History DM (-) HTN (-) Hepatitis (-) Pulmonary Tb (-) Operation Hx (-) Personal History Alcohol (-) Smoking (-) Travel Hx (-) Medication Hx (-) Herbal medication Hx (-) Family History Unremarkable History

20. Review of System General Fatigue (-) Febrile sensation (-) Chill (-) Wt Loss (-) Skin Rash (-) Pigmentation (-) Itching (-) H&N Headache (+) Sore throat (-) Jaundice (+) Respiratory Cough (-) Sputum (-) Dyspnea (-) Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) G-I Anorexia (+) Nausea (+) Vomiting (+) Dyspepsia (+) Abdominal pain (+) Diarrhea (-) Constipation (-) Abdominal pain (+) Diarrhea (-) Constipation (-) Renal Dysuria (-) Frequency (-) Hematuria (-) Back & Ext. Upper back pain (-) Lower back pain (-)

21. Physical Examination V/S 120/60 mmHg – 84 /min – 20 /min – 37.5 O C General Appearance Alert mental status Acutely ill-looking appearance Eye & ENT Isocoric pupil with PLR (++/++) Pinkish conjunctiva Icteric sclera Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound Tenderness (+) : epigastrium Rebound tenderness (-) Hepatosplenomegaly (-) Back & Ext. CVA tenderness (-/-) Pretibial pitting edema (-/-) Body weight: 53.1 Kg Height: 161.3 cm BMI: 20.4

22. Initial Laboratory Findings CBC/DC 6,970 /mm 3 – 13.8 g/dL – 40.3% – 274,000 /mm 3 (Seg 48%) Chemistry TB / DB 3.89 / 3.1 mg/dL Glucose 77 mg/dL Prot / Alb 7.1 / 3.5 g/dL Uric acid 3.2 mg/dL AST / ALT 7151 / 3031 U/L Cholesterol 74 mg/dL ALP / GTT 214 / 233 U/L BUN / Cr 11 / 0.6 mg/dL Na / K / Cl 135 / 4.0 / 96 mmol/L LD / CK 4154 / 15 U/L U/A RBC 0-1 / HPF WBC 0-1 / HPF Bilirubin (+++)

23. Initial Chest X-ray

24. Initial EKG

25. Initial Problem Lists #1. Acute hepatitis r/o Acute A viral hepatitis r/o Other viral hepatitis r/o Systemic viral disease

26. Diagnostic plan Viral marker Abdominal sono Therapeutic Plan Supportive care Symptomatic treatment Diagnostic & Therapeutic Plans

27. Viral marker Anti-HAV IgMpositive Anti-HAV IgGpositive Anti-HBc IgGreactive Anti-HBs Abpositive HBs Agnon-reactive Anti-HCVnegative Anti-HIVnegative Anti-CMV IgMnegative Acute A viral hepatitis !!

28. Clinical course (09.4.27 ~ 09.5.11) Ascites 발생, condition 저하

29. Abdominal sono (2009.4.28)

30. Abdominal sono (2009.5.4)

31. Clinical course after discharge (09.4.27 ~ 09.5.26) 퇴원

32. CASE 3 CASE 3

33. History 12044736 한○주 (M/26) Adm> 2009.4.30 Chief Complaint 두통 o/s> 내원 하루 전 Present illness 26 세 남환, 평소 특이병력 없던 자로 내원 하루 전 두통 발생하였으며 증상 호전되지 않아 응급실 경유 입원함

34. Past Medical History DM (-) HTN (-) Hepatitis (-) Pulmonary Tb (-) Operation Hx (-) Personal History Alcohol (+) : 주 2~3 회, 소주 한병 Smoking (+) : 6 pack-yrs Travel Hx (-) Medication Hx (-) Herbal medication Hx (-) Family History Unremarkable History

35. Review of System General Fatigue (+) Febrile sensation (+) Chill (+) Wt Loss (-) Skin Rash (-) Pigmentation (-) Itching (-) H&N Headache (+) Sore throat (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) G-I Anorexia (-) Nausea (+) Vomiting (-) Dyspepsia (+) Abdominal pain (-) Diarrhea (-) Constipation (-) Renal Dysuria (-) Frequency (-) Hematuria (-) Back & Ext. Upper back pain (-) Lower back pain (-)

36. Physical Examination V/S 120/80 mmHg – 84 /min – 20 /min – 39.4 O C General Appearance Alert mental status Acutely ill-looking appearance Eye & ENT Isocoric pupil with PLR (++/++) Pinkish conjunctiva Clear sclera Chest Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound Tenderness (+) Rebound tenderness (-) Hepatosplenomegaly (-) Back & Ext CVA tenderness (-/-) Pretibial pitting edema (-/-) Body weight: 97 Kg Height: 174 cm BMI: 32.04

37. Initial Laboratory Findings CBC/DC 5,010 /mm 3 – 16.7 g/dL – 47.9% – 194,000 /mm 3 (Seg 71.5%) Chemistry TB / DB 0.53 / 0.22 mg/dL Glucose 96 mg/dL Prot / Alb 6.9 / 3.9 g/dL Uric acid 3.2 mg/dL AST / ALT 1155 / 1080 U/L Cholesterol 102 mg/dL ALP / GTT 60 / 81 U/L BUN / Cr 8 / 0.8 mg/dL Na / K / Cl 138 / 4.0 / 101 mmol/L LD / CK 2477 / 115 U/L U/A RBC 0-1 / HPF WBC 2-4 / HPF Bilirubin (-)

38. Initial Chest X-ray

39. Initial EKG

40. Initial Problem Lists #1. Acute hepatitis r/o Acute A viral hepatitis r/o Other viral hepatitis r/o Systemic viral disease r/o Alcoholic hepatitis

41. Diagnostic plan Viral marker Abdominal sono Therapeutic Plan Hydration Symptomatic treatment Diagnostic & Therapeutic Plans

42. Viral marker Anti-HAV IgMnegative Anti-HAV IgGpositive Anti-HBc IgGreactive Anti-HBs Abpositive HBs Agnon-reactive Anti-HCVnegative Anti-HIVnegative Anti-HAV IgM negative !!

43. Abdominal sono (2009.5.4)

44. Viral marker 2009. 5. 4 Anti-HAV Ig M : negative 2009. 5. 7 Anti-HAV Ig M : positive

45. Clinical course after discharge (09.4.30 ~ 09.5.25) 퇴원

46. Summary Case 1 : Cholestatic pattern Case 2 : Fulminant hepatitis pattern Case 3 : Anti-HAV Ig M negative  positive ‘seroconversion’