A 28yr Old Man Comes To Your Office Complaining Of 5 Day History Of Nausea

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A 28-year-old man comes to your office complaining of a 5-day history of nausea, vomiting, diffuse abdominal pain, fever to 101°F, and muscle aches. He has lost his appetite, but he is able to tolerate liquids and has no diarrhea. He has no significant medical history or family history, and he has not traveled outside the United States. He admits to having 12 different lifetime sexual partners, denies illicit drug use, and he drinks alcohol occasionally, but not since this illness began. He takes no medications routinely, but he has been taking acetaminophen, approximately 30 tablets per day for 2 days for fever and body aches since this illness began. On examination, his temperature is 100.8°F. heart rate 98 bpm, and blood pressure 120/74 mmHg. He appears jaundiced, his chest is clear to auscultation, and his heart rhythm is regular without murmurs. His liver percusses 12 cm. and is smooth and slightly tender to palpation. He has no abdominal distention or peripheral edema. Laboratory values are significant for a normal complete blood count, creatinine 1.1 mg/dL. alanine aminotransferase (ALT) 3440 1U/L, aspartate aminotransferase (AST) 2705 IU/L, total bilirubin 24.5 mg/dL, direct bilirubin 18.2 mg/dL. alkaline phosphatase 349 IU/L, serum albumin 3.0 g/dL. and prothrombin time 14 seconds.

♦ What is the most likely diagnosis?

^ What is the most important immediate diagnostic test?

ANSWERS TO CASE 11: Acute Viral Hepatitis, Acetaminophen Exacerbation

Summary: A 28-year-old man complains of nausea, vomiting, diffuse abdominal pain, fever, and myalgias. He has had 12 different lifetime sexual partners and currently is taking acetaminophen. He appears icteric and has a low-grade fever and tender hepatomegaly. Results of his laboratory studies are consistent with severe hepatocellular injury and somewhat impaired hepatic function.

^ Most likely diagnosis: Acute hepatitis, either viral infection or toxic injury, possibly exacerbated by acetaminophen use.

^ Most important immediate diagnostic test: Acetaminophen level, because acetaminophen toxicity may greatly exacerbate liver injury but is treatable.


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