Jason Livermore, a 32-year-old bank manager, has been feeling tired and weak for several days. Two days ago he became nauseated and noticed a dull pain in his "stomach." He thought it was just intestinal "flu" but decided to seek your help the next day when he noticed that his urine had turned very dark and that his skin was somewhat yellow.
Question 1 - Single Best Answer
The yellow skin is called jaundice or icterus and results from an abnormal accumulation of which of the following compounds in the blood? Bugs Database
A) hemoglobin
B) albumin
C) urea
D) bilirubin
E) glucuronic acid
Question 2 - Single Best Answer
Bilirubin is normally removed from the bloodstream in the liver, conjugated with glucuronic acid and excreted via the bile. In considering possible causes of jaundice, one must consider things that would increase the production of bilirubin, or decrease its uptake and secretion. If its secretion is decreased there will be conjugated bilirubin in the blood. If its production is increased there will be unconjugated bilirubin in the blood. Things that might increase its production include? Bugs Database
A) blockage of bile flow through the small bile ducts in the liver
B) hepatocellular damage
C) carcinoma of the pancreas
D) none of the above
Question 3 - Single Best Answer
What are some of the things that could damage the liver and cause jaundice? Bugs Database
A) drugs
B) alcohol
C) viruses
D) bacteria
E) all of the above
Question 4 - Single Best Answer
Urine that is extremely concentrated often has a dark appearance. What is another thing that could make the urine dark? Bugs Database
A) protein
B) unconjugated bilirubin
C) conjugated bilirubin
D) breakdown products of urea
E) all of the above
Question 5 - Single Best Answer
Would you expect dark urine to accompany the jaundice if it were caused by viral damage to the liver? Bugs Database
A) yes
B) no
You find that Mr. Livermore has a slight fever. You question him about the pain and find that it is right upper quadrant pain. You also note that his liver is enlarged and tender. You order lab tests.
Some initial lab results were as follows:
Question 6 - Single Best Answer
What do the elevated AST and ALT indicate? Bugs Database
A) red blood cell lysis
B) viral infection
C) liver damage
D) sexually transmitted disease
Question 7 - Single Best Answer
Below are some lists of possible differential diagnoses. Pick the one that most closely agrees with your differential at this point. (Note: the diseases are listed in the order of the most likely to the least likely.) Bugs Database
A) liver tumor, alcoholic hepatitis, viral hepatitis, brucellosis
B) viral hepatitis, infectious mononucleosis, liver tumor, Lyme disease
C) viral hepatitis, CMV mononucleosis, leptospirosis, liver tumor
D) amoebic liver abscess, CMV mononucleosis, viral hepatitis
Question 8 - Single Best Answer
Leptospirosis is a bacterial disease, one of only a very few that can affect the liver. How is it transmitted? Bugs Database
A) from animals to man via urine-contaminated water
B) from animals to man via an insect vector
C) from animals to man via ingestion of undercooked meat
D) it is a sexually transmitted disease
Question 9 - Single Best Answer
How many Hepatitis viruses are there? Bugs Database
A) 1
B) 2
C) 5
D) 10
Question 10 - Single Best Answer
Which Hepatitis virus is in the same family as polio virus? Bugs Database
A) A
B) B
C) C
D) D
E) E
Question 11 - Single Best Answer
Which of the hepatitis viruses can be spread by contaminated food or water? Bugs Database
A) A only
B) A and E
C) B only
D) B, C, and D
E) none of them can be spread by food or water
Question 12 - Single Best Answer
A and E can also be spread another way. What is it? Bugs Database
A) respiratory
B) sexually
C) insects
D) kitty litter
Question 13 - Single Best Answer
What is the major route of transmission of Hepatitis viruses B, C, and D? Bugs Database
A) respiratory
B) fecal-oral
C) animal bite
D) blood
E) sexual
Question 14 - Single Best Answer
Does the patient's history help at all in diagnosing the cause of hepatitis? Bugs Database
A) Yes
B) No
You decide to take a better history and find that Mr. Livermore is married with two children. He has experienced fatigue, loss of appetite and mild diarrhea over a 7-10 day period. Answers to specific questions indicate that he has had no contact with other people who are jaundiced, has not traveled or been camping, and has consumed no drugs. He drinks alcohol socially on the weekends only. He became irritated about his sexual preferences and reiterated that he is a married man. He has not been to any "raw" (sushi or oyster) bars lately. He also has never had a transfusion.
Question 15 - Single Best Answer
Does the history help in your diagnosis? Bugs Database
A) definitely yes
B) definitely no
C) it makes some things less likely
Question 16 - Single Best Answer
Can you tell which Hepatitis virus is causing disease by the clinical signs? Bugs Database
A) Yes
B) No
You order some more specific tests and find the following:
(HBsAg is HBV surface antigen; anti-HBs is antibody to the surface antigen and anti-HBc is antibody to the HBV core antigen. Anti-HAV is antibody to the whole HAV virus.) Normal Lab Values
Question 17 - Single Best Answer
These results show? Bugs Database
A) he has HAV now and has had HBV in the past
B) he has a current infection with HAV and a reactivated HBV infection
C) he has a primary infection with HBV now and has had HAV in the past
D) he has a reactivated HBV infection now and has had HAV in the past
E) he is chronically infected with both HAV and HBV
It was determined that Mr. Livermore has active Hepatitis B and has had Hepatitis A in the past. He does not have infectious mononucleosis now (see initial lab results), another disease that can present with symptoms of hepatitis. After an explanation that his disease was highly contagious to all sexual partners, Mr. Livermore admitted that he was bisexual. He had multiple male sex partners once every two or three months when he went on business to San Francisco, as well as an ongoing relationship with his wife.
Question 18 - Single Best Answer
It was determined that Mr. Livermore's wife was not sick but HBV has a very long incubation period. How can we tell if Mrs. Livermore is currently infected? Bugs Database
A) HbsAg
B) anti-HBc IgM
C) anti-HBs IgG
D) anti-HBc IgG
E) more than one of the above
Question 19 - Single Best Answer
Mrs. Livermore was negative for HBsAg, anti HBc and anti HBs. How might she be protected from getting the infection? Bugs Database
A) condoms
B) vaccine
C) hyperimmune serum globulin
D) not having sex with her husband
E) all of the above
Question 20 - Single Best Answer
What other diseases is Mr. Livermore at risk for? Bugs Database
A) syphilis
B) AIDS
C) liver cancer
D) chronic Hepatitis B
E) all of the above
Generally, hepatitis is a self-limiting disease, although some people with Hepatitis B do become chronic carriers. They are not sick, but are a major source for the spread of the virus. Mr. Livermore's jaundice gradually disappeared over the next two months. He regained his appetite and began to feel better. His liver enzyme levels returned to normal. He was cultured for gonorrhea and a serum test for syphilis and HIV were done -- all were negative. Four of Mr. Livermore's sexual partners were immunized, as was his wife. Mr. livermore and his wife went to counseling as she was very unhappy with his life style, but they were divorced within a year.
