1. Put the preliminary diagnosis.

2. Conduct a differential diagnosis.

3. Determine the tactics of examination and patient management.

4. Can the patient be a donor?

Answer

1. The preliminary diagnosis: acute hepatitis C, anicteric form. Reasons: The data of epidemiological anamnesis (plasma donor), the clinical manifestations of the disease (weakness, loss of appetite), and data of laboratory inspection (increased ALT and 40 standards, a normal level of bilirubin). The absence of anti-HCV does not contradict this diagnosis, since antibodies to the HCV can be determined at a later date.

2. Differentiate followed with acute viral hepatitis of different etiology. Reject the assumption of other acute viral hepatitis allows no markers of hepatitis A and B.

3. hospitalization, repeated blood test markers of viral hepatitis (anti-HCV, RNA HCV), in confirming the diagnosis of AVHC - interferon, followed by clinical observation.

4. From the donation remove.

Task 4

The patient, 23 years old, fell ill acutely observed increase in body temperature up to 38.5 ° C, pain in eyeballs, aching bones and muscles, fatigue, malaise. After 3 days, loss of appetite and nausea, vomiting was twofold. After 6 days of onset he observed darkening of the urine, then appeared yellowness of the skin and sclera. Examined by the local doctor and hospitalized with suspected viral hepatitis.

From epidemiological anamnesis: a month ago, I returned from a trip to the Sea of ​​Azov, where rested for 2 weeks, ate in the dining room, drank not boiled water from the tank-filled 3 times a week.

On examination: complaining about the small weak. The appetite has recovered, no fever since the appearance of jaundice. The skin is clean, jaundice of the skin and sclera of moderate intensity, "spider veins" Not present, on the right shoulder tattoo made 2 years ago, but then there were a few episodes of intravenous drug use. Belly conventional configuration, palpation soft, painless in all departments. The liver is slightly increased, its edge protrudes from under the right hypochondrium to 2 cm in the midclavicular line, elastic consistency. The spleen is not enlarged.

In the study of blood parameters revealed increased levels of bilirubin (free fraction - 65 mmol / l related - 84 mmol / l) and the level of enzymes: AST - 2250 IU / L; ALT - 3670 IU / L (normal up to 40 U / L); thymol test ED 54 (the rate to 15 units); AP - 290 IU / L (normal 300). Leukocytes - 4,7h10 9 / l, stab - 3%, segmented - 67% monocytes - 4% lymphocytes - 26%. In the blood of antibodies to the HCV.

1. Put the preliminary diagnosis.

2. Conduct a differential diagnosis.

3. Determine the tactics of examination and treatment of the patient.

Answer

1. Is it possible to think about the presence of icteric viral HA in patients infected with HCV. About virus HA can be thought of on the basis of the typical clinical picture of the disease (acute onset, recurrence of the disease, preicteric period, accompanied by fever, flu-like and dyspeptic syndromes, normalization of temperature and feeling better on the background of the emergence of jaundice), hyperbilirubinemia, with a predominance of the direct fraction of bilirubin, a significant hyperenzymemia, zoom indicator thymol, epidemiological history data. Thus, a typical complex epidemiological, clinical and laboratory data allows to suspect Assembly, despite the detection of antibodies in the serum of blood to the HCV.

2. Differentiate followed with acute viral hepatitis of different etiology, especially with HCV, as a high level of trans aminaz and detection of antibodies to HCV may be the basis for the assumption of this diagnosis. However, the clinical picture of the disease (acute onset, fever, disappeared after the appearance of jaundice, flu-like symptoms), and epidemiological history data (consumption of raw water stored in the tank) characteristic of the HA. Probably infected HCV appeared earlier (in history there are indications of drug use, tattooing was done). To eliminate HBV with delta-agent and without the need to study the blood serum HBsAg, anti-HBc IgM, anti-IgM and IgC delta.

3. To confirm the diagnosis requires the study of antibodies to the IgM class of NAU. As part of the HA treatment it is advisable to conduct basic treatment (see. Table. 17). Clinical supervision after discharge from the hospital is not only necessary for the monitoring period of convalescence GA, but also to clarify the current version of HCV infection, depending on which is determined by the further tactics of treatment and patient management. The necessary studies of biochemical parameters in serum, determination of RNA and genotype HCV holding needle biopsy of the liver might then will decide on the feasibility of antiviral therapy HCV- infection.

Task 5

The patient, 19 years old, fell ill nine days ago, when the background of the general, malaise, weakness and reduce disability (works as a courier) were pains in the shoulder and ankle joints, more pronounced in the morning and in the first half of the day and dies down in the evening, increased body temperature to 37,7-38 ° C, was shivering. About a week ago, he lost his appetite, there vomiting, yesterday was twice vomiting, low-grade fever continued. Two days ago, the patient noted the appearance of dark urine, and today co-workers noticed yellowness sclera. Examined by a doctor of the health and was hospitalized with suspected viral hepatitis.

On examination: complains of marked weakness, poor appetite (up to the aversion to food), headache, and drowsiness during the day. In the morning was the single vomiting. At the change of body position - dizziness. The body temperature of 38,5 ° C. Joint pain subsided. The skin is dry, the elements of vulgar rash on the chest and back, on the elbow - "track" (traces of intravenous heroin injection is used for 1.5 years), jaundice of the skin and sclera bright. Belly conventional configuration, palpation soft, painful in the right upper quadrant. The liver is slightly increased, its edge protrudes from under the right hypochondrium to 2 cm in the midclavicular line, texture rather compact. The spleen is increased. Consciousness is clear, oriented in space and time is correct, but sluggish, adynamic. "Clap" tremor, "hepatic" no odor.

At a blood analysis revealed elevated bilirubin levels (its the free-fraction - 105 mmol / l, connected - 84 mmol / l) and the level of enzymes: AST - 3250 IU / L; ALT - 2670 IU / L (normal up to 40 U / L); pro- thrombin index of 48%. Leukocytes - 3,9h109 / l stab - segmented 1% - 69% monocytes - 6%, lymphocytes - 24%. HBsAg found in the blood, and antibody to HCV.

1. Put the preliminary diagnosis and justify it.

2. Conduct a differential diagnosis.

3. Determine the tactics of the patient survey.