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You are the new FY1 on General Medicine at your local hospital. It is your first day, and you have been asked to come help out in clinic as the FY2 has called in sick. Arthur Itis is a 32 year old gentleman who has presented to the clinic. He had episodes of vomiting and fever just over two months ago, and was admitted to hospital. During this admission, he received a diagnosis of a chronic illness. He was then stabilised and discharged.

Please take a history from Arthur and perform the appropriate examination. Ensure that you undertake a relevant history of presenting complaint and address his concerns.

You are Arthur Itis, a 32 year old man who has had a difficult last six months. You are currently unemployed and are determined to improve your health and turn your life around. You became addicted to heroin from the age of 28 until around 5 month ago. Recently, events have spiralled out of control: you left your job as a waiter after an argument with a customer, and you lost your home soon after as you were unable to pay your rent. To make matters worse, you began to experience frequent episodes of vomiting and began to feel absolutely rubbish, and you just could not explain why. This is why you presented to hospital.

HPC: The vomiting started 6 months ago and lasted for 1 week, before it became too much to handle. It became progressively worse, and was not related to eating or position. There was no pattern in the timing of the vomiting.

You also experienced sweating episodes, usually at night, when you felt really warm. You felt generally more wiped out and not yourself. Your bowels had been mostly ok, but you had occasional episodes with dark stools and some tummy pain too. You lost your appetite completely during this time.

You did not have any rashes. You were unsure if you had lost any weight, since you had not been weighing yourself. You do not have any family or close friends to tell you if you have lost any weight. You did not have any tummy swelling. You did not notice any jaundice.

You have not been abroad recently, as you cannot afford it. You have not been in contact with anyone who is unwell, and you have not received any blood transfusions. You have one tattoo, of a pelican, on your arm, but that was done years ago.

When you were admitted, you were in a pretty bad place. You were still addicted to heroin, therefore were put on a replacement therapy and advised to stop taking drugs. The doctors did some blood tests and found that you had a virus called Hepatitis C. You understood that this was a serious, long term infection and were therefore shocked into deciding that you wanted to change your life. You have not taken heroin since this admission and have been successfully weaned off methadone.

ICE: You have always been terrified of going to hospital, but the vomiting and feeling ill gave you no other choice. You were shocked when you found out you had hepatitis, and the doctors have told you that this was likely due to your drug use.

PMH: You did not have any past medical problems diagnosed prior to the last admission, as you completely refused to go to the doctor when unwell. You think you might have asthma, as you occasionally have a cough and smoke heavily, but nothing else.

SH: You live in sheltered accommodation and are looking for ways to find a new job and a flat to rent. You are spending your time volunteering in the local homeless shelter, as your experience of homelessness terrified you, and moved you to help those who have experienced something similar. You still smoke, but not as much as before as it has proven too expensive. You smoke 5 cigarettes a day, but more if you can. You used to drink alcohol, around 10 cans of lager per week, but have stopped completely. You are no longer taking heroin.

FH: You don’t have any close family that you know of so you are unaware of any medical problems running in the family.

The student should demonstrate a clear history of the abdominal symptoms Arthur has been experiencing. In terms of examination, an abdominal exam would be appropriate. The student’s differential diagnosis should sound something like:

My differential diagnosis would include a hepatic cause, more specifically viral hepatitis. This is made more likely by the patient’s risk factors. I would also want to include other hepatic causes, such as alcoholic hepatitis. Surgical causes of this patient’s presentation could include obstructive pathology: specifically gallstones causing biliary colic or cholecystitis.
Example for discussion may include:

  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • How is hepatitis C transmitted?
  • How likely is this patient to develop chronic hepatitis C?
  • What are the long term complications associated with hepatitis C?
  • How do hepatitis A, B and C differ?
  • Can you talk to me about prevention measures for hepatitis C?
  • What tests can be done for Hepatitis B? What do the serological markers mean?