NAME : NURUL AQILA BINTI RAMLEE

CASE : HEPATITIS C
PRESENTED TO : DR.DIANA KATIMAN

HISTORY

Mister Abu , a 57 years old Malay man , came to the Selayang Hospital for electively follow up to
initiation of therapy for Hepatitis C.

He was previously well and always went to regular check-up at Private Clinic at Ampang, Until in late
2012, the doctor tell him, there is some abnormalities in the blood and referred him to Sungai Buloh
Hospital. The doctor at Sungai Buloh Hospital detected there is some problem at his liver and then
referred him to Selayang Hospital. In June 2013, he was diagnosed with hepatitis C associated with
Chronic Liver Diseases (CLD) . After that he has to come to Selayang Hospital every month for regular
check-up.

Patient also stated that currently he always got fever. The fever was intermittent in nature, occur at the
daytime only, almost every day. There is no chills and rigors. He always feel lethargy and some body
weakness. He did not take anything to relieve the fever.

Upon questioning, there is :

X Loss of weight & Loss of appetite to exclude malignancy
X Altered consciousness to check for hepatic encephalopathy
X UTI symptoms to check for hepato-renal syndrome
X Pruritus
X Pain after taking food- to exclude cholelithiasis

PAST MEDICAL HISTORY : diagnosed with TB in 1980s at General Hospital Kuala Lumpur and undergo
treatment for 2 years .

FAMILY HISTORY :
Father : died at the age 75 years old due to old age
Mother: died at the age 80(++) due to “penyakit busung “
~both no HPT , no DM
*no h(x) of malignancy
* 2nd child out of 9 siblings .(ALL OF HIS SIBLINGS ARE WELL)

SOCIAL HISTORY :
 Did not work and never work before
 Smoking- 20 cigarettes per day when he was young (not sure when he start smoking). Stop at the
age of 50 years old.
 Alcohol drinker 2/3 bottles of BEER everyday (evening until midnight) .Start drink alcohol when
he was 20 (++) years old.
 History of IVDU admits needle sharing
 Bachelor, however admits do one night stand with different woman everyday . He did not practice
safety sex.

PHYSICAL EXAMINATION

General examination : jaundice and clubbing

Abdomen examination : no stigmata of Chronic Liver disease.
Part 1 : DISCUSSION OF HISTORY AND PHYSICAL EXAMINATION
History

1) Ask about risk factor of liver disease

a. Alcohol----------------> liver cirrhosis , CLD
b. Sexual promiscuity
c. Blood transfusion HEPATITIS,CLD
d. Direct contact
*dan byk lagi . hahaha

2) Calculate cigarettes pack year

a. (no.stick per day)

20 (due to 1 pack of cigrattes x Years of smoking
contain 20 stick)

HEPATITIS,CLD
3) Alcohol units
 Safe recommendation of alcohol intake in UK for weekly consumption
o Woman : 14 units (if >35 units : high risk)
o Male : 21 units (if >50 units : high risk)

4) Alcohol (always ask for CAGE questionnaire to measure alcoholism severity)

a. C---> ever felt you ought to cut down your drinking ?
b. A---> have people annoyed you by criticizing your drinking?
c. G---> Ever felt guilty about your drinking?
d. E---> Ever have eye-opener to steady nerves in the morning ?
Physical Examination

STIGMATA OF CHRONIC LIVER DISEASES

1) HANDS
 Leukonychia
 Koilonychia
 Palmar erytherma
 Clubbing
o Stages of clubbing
 Increase fluctuancy of nail bed
 Loss of angle
 Increase curvature
 Drum-stick appearances.
 Hyperthropic pulmonary osteoathropathy
 Spider nevi more than 5
 Asterixis
*also check if there is any tattoo , drug injection site (during inspection) .

2) FACE AND HEAD

 Hepatic encephalopathy
o Stage : West-Haven Staging
STAGE 1 ALTERED MOOD/BEHAVIOUR/SLEEP DISTURBANCE
STAGE 2 INCREASING DROWSINESS, CONFUSION, SLURRED SPEECH
STAGE 3 STUPOR, INCOHERENCE AND RESTLESSNESS
STAGE 4 COMA X___X

 Jaundice at sclera
 Fetor hepaticus

3) CHEST
 Spider nevi
 Gynecomastia
 Loss of axillary hair

4) ABDOMEN
 Ascites
o How to look for causes of ascites ??
o The Answer is : SERUM ASCITES ALBUMIN GRADIENT (SAAG)
measurement
HIGH GRADIENT (>11g/L) LOW GRADIENT (<11g/L)
*indicate could be due to Portal Hypertension
Nephrotic syndrome
Cirhossis Cardiac failure Pancreatic and Biliary ascites
Alcoholic Hepatits Budd chiari syndrome Peritoneal TB
Fulminant Hepatic Failure

 Hepatomegaly
DIFFERENTIAL DIAGNOSIS

DIAGNOSIS POINT TO SUPPORT POINT TO AGAINST

HEPATITIS  IVDU  NO ALTERED

 ALCOHOLISM CONSCIOUSNESS
 MULTIPLE SEXUAL PARTNER  ABDOMEN EXAMINATION
DOES NOT SHOW STIGMATA
OF CLD
LIVER CIRRHOSIS  ALCOHOLISM FOR LONGER  PROLONGED HEPATITIS
TIME

HEPATOCELULLAR CARCINOMA  ALCOHOLISM  NO LOW & LOA
 HAD HEPATITIS/LIVER
CIRHOSSIS
ACUTE PANCREATITIS  ALCOHOLISM  NO EPIGASTRIC PAIN
 NO LOW & LOA
 NO NAUSEA & VOMITING
 NO CULLEN & TURNER SIGN

BILIARY OBSTRUCTION DZ  JAUNDICE  NO LOW & LOA

  NO HEPATOMEGALY

INVESTIGATION

1. FBC:
 Hb level (anemia of chronic disease and hematemesis)
 WCC infection (spontaneous bacterial peritonitis,SBP)
 Platelet thrombocytopenia
2. Renal profile:
 Disproportionate urea to creatinine ratio (normal creatinine 20x from urea level) due to
dehydration and UGIB
 hypernatremia
 Potasium level-->low
3. LFT: low albumin, normal or increase bilirubin, normal or increase ALT/AST. In alcohol causes can have
isolated increase GGT
4. Coagulation profile: prolong PT
5. Serology test:
 Hep B surface Ag (usually present >6month infection)for screening
 Hep B core Ig G(persist if have previous infection, not doing routinely, not for screening)
 Hep B Envelope Ag (indicate cute flare), if increase AST/ALT proceed with viral load
 Hep C cytology test
 HIV serology test (western blot)
6. OGDS--->to check for varices.
7.ultrasound : check for any mass , stone, dilatation of duct , nodularity.
8.Tumor marker : Alpha fetoprotein.