Walter works as a salesman for a software development firm.

In connection with his job, he frequently travels to

countries throughout the world. Walter goes on a sales trip to Southeast Asia, and after his business trip is finished,
spends 2 extra weeks touring the ancient ruins of Thailand and sampling the night life in Bangkok. About 3 months
after his return, Walter notices that he is constantly tired, has a slight fever, and often feels nauseous. Although
Walter normally enjoys a good dinner with cocktails and is a smoker, he now has little interest in eating and finds
cigarettes and alcohol distasteful.
A few days of these symptoms, Walter thinks that he is improving and returns to his normal activities. But the
next week he notices that his urine has turned a dark color and his abdomen is slightly tender. Fearing that he
may have contracted a disease on his trip, Walter makes an appointment to see his physician the next day.
The physician completes a physical examination and notes that Walter’s corneas and oral mucosa are
slightly yellowed. Since Walter is slightly tanned from his travels, this jaundice is not apparent in his skin, but is
present there as well. In completing the patient history, the physician asks Walter about his immunization record and
his activities during his travels. Walter is current for most immunizations (mumps, measles, diphtheria, polio). He says
that he thought of getting vaccinated for hepatitis before his trip, but decided against it because he did not have time
to complete the series. Walter mentions that he is always careful to drink bottled water during his travels. Afraid that
he might have AIDS, Walter finally confides that he had sexual relations with both men and women in his home
territory and on his stay in Asia, although he says that all of his partners appeared healthy.
Results of the physical examination and blood test are shown here:
Vital Signs:
Oral temperature = 98.7oF (37.1oC)
Heart rate = 74 beats/min
Respiratory rate = 13 breaths/min
Blood pressure = 136/76 mmHg
Physical Examination:
Skin and mucous membranes: Yellow tinge but otherwise normal
Musculoskeletal: No abnormalities noted
Nervous and sensory: No abnormalities noted
Cardiovascular: No abnormalities noted
Respiratory: No abnormalities noted

Abdominal organs: Hepatomegaly; slight splenomegaly; normal bowel sounds; hepatic tenderness and pain
upon percussion and palpation

Blood Test:
Serum aspartate transaminase = 595 IU/L
Serum alanine transaminase = 1,948 IU/L
Serum Bilirubin = 1.1 mg/dL
Negative for HIV antigens
Positive for Hepatitis B antigens
All other blood work was normal

Based on these results, Walter is diagnosed with hepatitis B. His physician tells him the disease will most
likely run its course and he will recover within a few weeks. In the meantime, he advises Walter to limit his physical
activity until his appetite returns and to go back to work only after his jaundice resolves. He points out that a follow-up
examination is necessary because of the slight possibility of the infection developing into chronic hepatitis, which
would require further treatment.

The physician also suggest that Walter consider following a low-fat, high carbohydrate diet, although this is
not essential to is recovery. Finally, he counsels Walter about the importance of using condoms and controlling his
sexual activity to minimize the chance of contracting sexually transmitted diseases in the future.

Based on the case study answer the following questions:

1. What factors in Walter’s history suggest a tentative diagnosis of hepatitis? His travels to Asia,
sexual relation with both men and women, in the states and in Asia, and not having
immunizations against Hepatitis B.
 2. What laboratory findings confirm this diagnosis? The laboratory findings positive for Hepatitis B
antigens and an increase in Serum aspartate transaminase, Serum alanine transaminase,
and Serum bilirubin.
3. Without the laboratory findings, why would you be unlikely to suspect hepatitis A? Hepatitis A is
spread by contaminated food or water.
4. If Walter were to develop chronic hepatitis, he would be at high risk of cirrhosis of the liver. What
additional signs and symptoms would indicate that he had developed chronic hepatitis?
Symptoms: Fatigue, fever, nausea, loss of interest in eating or drinking; Signs: Urine turns
dark, abdomen tenderness, jaundice (skin & eyes)
5. One of the functions of the liver is to produce most of the proteins of the blood plasma. What
happens to plasma proteins when a patient has reduced liver function? Plasma protein (like
albumin) production would decrease. Which will cause ascites or edema of the abdomen.
Decrease in plasma proteins makes the patient more prone to bruising.

Symptoms
 Fatigue
 Slight fever
 Nauseous
 No interest in eating or drinking
 Finds cigarettes and alcohol distasteful

Signs
 Urine turns dark
 Abdomen is tender
 Jaundice