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PATIENT 
Mr. R is a 24-year-old graduate student with no past medical history who comes to see you because his girlfriend thought his eyes looked yellow yesterday. He has felt tired and a bit queasy for the last couple of weeks but thought he was just overworked and anxious. He has had some aching pain in the right upper quadrant and epigastrium, not related to eating or bowel movements. He has had no fevers, chills, or sweats. He has noticed dark urine for 1 or 2 days but attributed it to not drinking enough.
On physical exam, he appears tired. He has scleral icterus; his liver is palpable 2 cm below the costal margin and is mildly tender. The spleen is not palpable, and the rest of his abdomen is nontender and nondistended. He has no edema, and the rest of his exam is normal.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
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RANKING THE DIFFERENTIAL DIAGNOSIS
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The differential diagnosis for fatigue, nausea, and vague abdominal pain is broad, but the pivotal findings of scleral icterus and tender hepatomegaly point toward a hepatic source.
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Mr. R’s clinical picture is consistent with that of the majority of patients with viral hepatitis: a history of anorexia, malaise, and nausea, and a physical exam showing hepatomegaly, hepatic tenderness, or both. Hepatitis A is the most frequent cause of acute viral hepatitis; hepatitis C is the second most frequent but is usually asymptomatic acutely. Hepatitis B can also present acutely. By virtue of being common, alcoholic hepatitis is another active alternative diagnosis, and the presentation can mimic that of viral hepatitis. Biliary obstruction is always a consideration in patients with jaundice, but the prodrome and type of abdominal pain are not typical. Table 26-3 lists the differential diagnosis.
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