Case study Hepatitis

1. Case Study
Hepatitis

2. Patient’s Profile
• Name: Mr. Grey
• Sex: Male
• Age: 37
• Civil status: Unmarried
• Date admitted: 15/03/15
• Time: 17:26
• Weight: 72 kg
• Height: 184 cm

3. Complaints
• General weakness
• Headache
• Restlessness
• Loss of sleep

4. History of present illness
• Mild headaches, restlessness and the loss of
sleep started occurring 6 months ago.
• General weakness began 3 weeks ago.
• The intensity of headache increased since
then.
• There weren’t any additional symptoms.

5. Personal History
• There weren’t any previous hospitalizations
• There are no records of substance abuse
• Currently is not under any medications except
the occasional usage of ibuprofen for the
headaches (1-2 times per day)
• No records of alcoholism or tobacco smoking
• Sexually active with several partners

6. Family History
• There are no cancer histories
• There were no Hepatitis B, Uterine Fibroid and
Heart diseases from the mother’s side

7. Examination findings
• No abnormal findings
• No manifestations of jaundice or
hepatosplenomegaly
• Appetite is mildly diminished
• Normal urine and stool output

8. Laboratory Findings
• AST: 349
• ALT: 452
• Total bilirubin: 0.9
• Platelet count: 210k
• HBsAg: positive
• HBeAg: negative
• Anti-Hbe: positive
• Anti-HCV: negative
• HBV DNA 110 IU/mL

9. Ultrasound
• Liver normal size and texture with no mass,
borderline splenomegaly

10. Inactive carrier state
• HBeAg negative
• Persistently normal ALT
• Serum HBV DNA persistently undetectable or
< 2000 IU/mL
• Several follow-ups necessary to differentiate
inactive carriers from patients with HBeAg-
negative chronic hepatitis B and intermittently
normal ALT