HISTORY. Question the patient about potential sources of transmission and risks: a history of blood dyscrasias, multiple blood or blood product transfusions, alcohol or drug abuse (sharing of needles), exposure to hepatotoxic chemicals or medications, and travel to third world countries or areas where the sanitation is poor. Since HAV transmission occurs in association with daycare centers, among male homosexuals, and among household contacts of persons with acute cases, inquire into these areas. Also ask about recent meals, because hepatitis A occasionally occurs from contaminated food or improper sewage treatment. Determine the patient's occupation; teratogen exposure may cause a nonviral hepatitis.

Patients in the prodromal (initial) phase may complain of nausea, vomiting, malaise, headache, fatigue, anorexia (a distaste for cigarettes in smokers is characteristic of early profound anorexia), and fever. Ask about any changes in the sense of taste or smell, recent weight loss, and the presence of urticaria or arthralgias, which can occur early in the disease process. Pruritus may be mild and transient and is caused by the accumulation of bile salt in the skin. In the icteric phase (3 to 10 days later), there may be right upper-quadrant pain and no flulike symptoms.

PHYSICAL EXAMINATION. In the prodromal phase, inspect the skin for a rash. Fever is usually between 101°F and 102°F. In the icteric phase, the urine often appears dark and concentrated. Observe stools for a pale, clay color. Inspect the skin, sclera, and mucous membranes for jaundice, which is caused by the poor ability of the damaged liver to remove bilirubin from the bloodstream. Jaundice peaks within 1 to 2 weeks and fades during the recovery phase over the next 2 to 4 weeks.

On palpation, the liver is usually enlarged and sometimes tender. The edges remain soft and smooth. In 15% to 20% of cases, mild splenomegaly is present. In uncomplicated cases, signs of chronic liver disease are not seen. In alcoholic hepatitis, inspect the skin for spider nevi.

Potential complications include bleeding and the possibility of progressive liver degeneration. Assess for petechiae, bruising, bleeding gums or nose, prolonged bleeding from puncture sites, and obvious or occult blood in body secretions and fluids. Note that restlessness and confusion, decreasing blood pressure and pulse, abnormal complete blood count, and platelet and coagulation tests may indicate increased bleeding. Monitor for worsening symptoms, edema, ascites, and encephalopathy. Because an early sign of hepatic encephalopathy is deterioration of the handwriting, have the patient write his or her name each shift and monitor the signature for changes.

PSYCHOSOCIAL. The patient with hepatitis has a communicable disease. Assess for knowledge of possible sources of transmission, including behavioral risk factors. Ask about the patient's living conditions to assess the risk of spread of hepatitis to the family and significant others. Determine the patient's ability to cope with a communicable disease, anxiety level, and support mechanisms. Some families have a magnified fear of contracting a communicable disease and may respond to the diagnosis with irrational fears and concerns.

Diagnostic Highlights

A Disquistion On The Evils Of Using Tobacco

A Disquistion On The Evils Of Using Tobacco

Among the evils which a vitiated appetite has fastened upon mankind, those that arise from the use of Tobacco hold a prominent place, and call loudly for reform. We pity the poor Chinese, who stupifies body and mind with opium, and the wretched Hindoo, who is under a similar slavery to his favorite plant, the Betel but we present the humiliating spectacle of an enlightened and christian nation, wasting annually more than twenty-five millions of dollars, and destroying the health and the lives of thousands, by a practice not at all less degrading than that of the Chinese or Hindoo.

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