Case Study

Hepatitis

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

Complaints

• General weakness• Headache• Restlessness• Loss of sleep

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.

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

Family History

• There are no cancer histories• There were no Hepatitis B, Uterine Fibroid and

Heart diseases from the mother’s side

Examination findings

• No abnormal findings• No manifestations of jaundice or

hepatosplenomegaly• Appetite is mildly diminished• Normal urine and stool output

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

Ultrasound

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

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