History of Present Illness The patient was apparently well until one month ago, when he developed a gradual onset of loss of appetite associated with intermittent vomiting. The vomiting occurred in 1–2 episodes on alternate days, was non-projectile, and contained food particles (modify if different). Following this, he developed severe abdominal pain. The pain was gradual in onset and has persisted since then (add the site, character, radiation, severity, aggravating and relieving factors if known). A few days later, the patient noticed yellowish discoloration of the urine, which progressively became darker. Subsequently, he developed yellowish discoloration of the sclera and later of the palms, suggestive of progressive jaundice. During the course of the illness, he developed an episode of loose stools with blood one month ago, occurring 2–3 times in a day. Today, he again developed diarrhea associated with blood in the stools. He also reports that his urine is now red in color. The patient therefore presents with a one-month history of anorexia, intermittent vomiting, severe abdominal pain, progressive jaundice, recurrent bloody diarrhea, and red-colored urine. Write case presentation
Here is a structured case presentation based on the history provided:
Case Presentation
Patient: [Name] | [Age] | [Sex] | [Occupation] | [Address]
Chief Complaints
- Loss of appetite - 1 month
- Intermittent vomiting - 1 month
- Severe abdominal pain - 1 month
- Progressive yellowish discoloration of sclera and skin - less than 1 month
- Recurrent bloody diarrhea - 1 month (recurred today)
- Red-colored urine - today
History of Present Illness
Mr. [Name], a [age]-year-old [male/female], was apparently well until one month ago, when he first developed loss of appetite of gradual onset. This was associated with intermittent, non-projectile vomiting, occurring in 1-2 episodes on alternate days, containing food particles, with no bile or blood noted.
Shortly thereafter, he developed severe abdominal pain of gradual onset, which has been persistent since then. [Site, character, radiation, severity, aggravating and relieving factors to be added once available.]
A few days into the illness, the patient noticed darkening of the urine, which was progressive in nature. This was followed by the appearance of yellowish discoloration of the sclera and subsequently the palms, indicating progressive jaundice. There was no associated pruritus, pale stools, or fever reported at this time. [Add if present or absent.]
Concurrently, approximately one month ago, he experienced an episode of loose stools mixed with blood, occurring 2-3 times per day. This resolved but has recurred today. On the same day, the patient also noticed that his urine has turned red in color, raising concern for hematuria or hemoglobinuria.
The patient therefore presents with a one-month history of:
- Anorexia
- Intermittent non-projectile vomiting
- Severe abdominal pain [details pending]
- Progressive jaundice (dark urine → scleral icterus → palmar yellowing)
- Recurrent bloody diarrhea
- Acute onset red-colored urine
Pertinent Positives and Negatives (to be completed on review)
| System | Positives | Negatives (to confirm) |
|---|---|---|
| GI | Anorexia, vomiting, abdominal pain, bloody diarrhea | Fever, weight loss, tenesmus, mucus in stool |
| Hepatobiliary | Progressive jaundice, dark urine | Pruritus, pale/clay-colored stools, hepatic encephalopathy |
| Urinary | Red urine | Dysuria, frequency, flank pain |
| General | - | Night sweats, travel history, sick contacts |
Synthesis and Working Differential
This presentation - combining progressive jaundice, abdominal pain, anorexia, bloody diarrhea, and now red urine - suggests a systemic process rather than isolated organ disease. Key differentials to consider include:
- Enteric fever with hepatitis (Salmonella typhi) - common in endemic regions; can cause hepatosplenomegaly, GI bleeding, and jaundice
- Leptospirosis - classic triad of jaundice, renal involvement (red urine/hematuria), and GI symptoms; Weil's disease presentation
- Viral hepatitis (A, E) with GI involvement - hepatitis A/E can cause jaundice and bloody diarrhea in acute phase
- Hemolytic anemia (e.g., G6PD deficiency, malaria) - hemolysis explains jaundice + hemoglobinuria (red urine) + GI symptoms
- Malaria (Plasmodium falciparum) - blackwater fever can produce hemoglobinuria, jaundice, and GI symptoms
- Cholangiocarcinoma or pancreatic malignancy - obstructive jaundice + abdominal pain in an older patient
Points Requiring Clarification
- Exact site, character, and radiation of abdominal pain
- Travel history, animal/water exposure (leptospirosis risk)
- Fever or rigors at any point
- Weight loss quantification
- Drug history, alcohol use, herbal remedy use
- Family history of hemolytic disorders or liver disease
- Vaccination history (Hepatitis A/B)
- Whether stools became pale/clay-colored at any point
- Occupational exposure
[Proceed to Past Medical History, Family History, Social History, Systemic Review, Examination Findings, and Investigations as appropriate.]
Hbs positive
With HBsAg positive, the diagnosis now anchors firmly on Hepatitis B infection. Here is the updated and refined case presentation:
Case Presentation
Patient: [Name] | [Age] | [Sex] | [Occupation] | [Address]
Chief Complaints
- Loss of appetite - 1 month
- Intermittent vomiting - 1 month
- Severe abdominal pain - 1 month
- Progressive jaundice - less than 1 month
- Recurrent bloody diarrhea - 1 month (recurred today)
- Red-colored urine - today
History of Present Illness
Mr. [Name], a [age]-year-old [male/female], was apparently well until one month ago, when he developed a gradual onset of anorexia associated with intermittent non-projectile vomiting, occurring in 1-2 episodes on alternate days, containing food particles, with no bile or hematemesis.
Shortly thereafter, he developed severe abdominal pain of gradual onset, which has persisted since. [Site, character, radiation, aggravating/relieving factors to be added.]
A few days into the illness, he noted progressive darkening of the urine, followed by yellowish discoloration of the sclera and subsequently the palms, indicating progressive jaundice - a pattern consistent with hepatocellular jaundice. [Confirm presence or absence of pruritus, pale stools, fever.]
Concurrently, approximately one month ago, he developed bloody loose stools, occurring 2-3 times per day. This has recurred today, alongside the new onset of red-colored urine - which in this context may represent hematuria, hemoglobinuria, or bile pigmenturia and warrants urgent evaluation.
Serology
- HBsAg: Positive - confirming active Hepatitis B virus (HBV) infection
Assessment
This patient presents with acute or acute-on-chronic Hepatitis B, manifesting as:
| Feature | Significance in HBV Context |
|---|---|
| Anorexia + vomiting | Prodromal phase of acute hepatitis |
| Progressive jaundice (dark urine → icteric sclerae → palmar icterus) | Hepatocellular jaundice from hepatocyte injury |
| Severe abdominal pain | Hepatic capsule stretch from hepatomegaly; rule out acute liver failure |
| Bloody diarrhea (recurrent) | Possible HBV-associated vasculitis (PAN), coagulopathy, or portal hypertension if chronic |
| Red urine | Hemoglobinuria, hematuria (IgA nephropathy / membranous nephropathy associated with HBV), or bilirubinuria |
Differential Diagnosis
Given HBsAg positivity, the working differentials are now stratified:
Primary Diagnosis:
- Acute Hepatitis B - classic prodrome of anorexia, vomiting, jaundice with HBsAg positivity
Complications to exclude:
- Acute Liver Failure (ALF) - severe abdominal pain + deep jaundice + any encephalopathy = urgent screen (PT/INR, ammonia, glucose)
- HBV-associated nephropathy - membranous nephropathy or IgA nephropathy causing red urine/hematuria
- Polyarteritis Nodosa (PAN) - HBV-associated vasculitis; can explain abdominal pain and bloody diarrhea
- Acute-on-chronic HBV with decompensated cirrhosis - if chronic HBV was previously undiagnosed; ascites, variceal bleed (bloody diarrhea/melaena)
- HBV + HDV co-infection or superinfection - produces more severe disease; check anti-HDV
- Coagulopathy-induced GI bleed - liver synthetic failure reducing clotting factors
Urgent Investigations to Request
Liver function and severity:
- LFTs (bilirubin - direct/indirect, ALT, AST, ALP, GGT, albumin)
- PT / INR (marker of synthetic function - key for ALF diagnosis)
- Serum ammonia
- Blood glucose (hypoglycemia in ALF)
- Serum proteins
HBV workup:
- HBeAg / Anti-HBe
- Anti-HBc IgM (acute infection marker) vs IgG (chronic/past)
- HBV DNA (viral load)
- Anti-HDV (rule out delta co-infection)
Renal and urine:
- Urine microscopy (RBCs, casts, bile pigments)
- Urine dipstick (bilirubin, urobilinogen, blood)
- Serum creatinine, urea, electrolytes
- 24-hour urine protein (if nephropathy suspected)
GI bleed workup:
- Stool microscopy and culture
- Stool occult blood
- Upper GI endoscopy if variceal bleed suspected
General:
- CBC with differential (thrombocytopenia in cirrhosis/hypersplenism)
- Blood cultures (rule out secondary bacterial infection)
- Abdominal ultrasound (liver size/echogenicity, portal hypertension, ascites, biliary dilatation)
- Anti-HCV, HIV screen (co-infections)
Red Flags Requiring Immediate Attention
- Altered sensorium / flapping tremor → hepatic encephalopathy
- INR > 1.5 + jaundice → acute liver failure criteria
- Massive rectal bleed → variceal hemorrhage
- Oliguria + rising creatinine → hepatorenal syndrome
[Proceed to Past Medical History - specifically prior jaundice, known liver disease, blood transfusions, IV drug use, sexual history, family HBV status | Social History | Examination Findings | Investigations]
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