A 45-year-old male presents for a routine checkup because he wishes to purchase life insurance. He says he feels "perfectly healthy" and has no complaints. His medical history is significant for a remote bout of cellulitis and a fractured clavicle from playing football in high school. He works as a supervisor at a corporate call center. He is monogamous and lives with his wife and two children. Laboratory testing reveals the following: Liver studies
Complete blood count
Chemistry panel
What is the next best step in the evaluation of this patient?

Question

A 45-year-old male presents for a routine checkup because he wishes to purchase life insurance.  He says he feels "perfectly healthy" and has no complaints.  His medical history is significant for a remote bout of cellulitis and a fractured clavicle from playing football in high school.  He works as a supervisor at a corporate call center.  He is monogamous and lives with his wife and two children.  Laboratory testing reveals the following: Liver studies
 Complete blood count
 Chemistry panel
 What is the next best step in the evaluation of this patient?

Quizplus · Accepted Answer

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are distributed widely throughout the body, with AST present and very active in the liver, heart, kidney, and skeletal muscle. While ALT is also present in reduced quantities in the kidney, heart, and skeletal muscle, it is predominantly found in the liver and is therefore more specific for hepatocyte injury. The patient in this scenario has a mild (< 250 U/L), asymptomatic elevation of his serum transaminases. The first step in the evaluation of his condition should be a careful screening for all hepatitis risk factors, including drug and alcohol intake, travel outside the United States, blood transfusions, or high-risk sexual practices. This aspect of the patient's history will provide insight as to whether the transaminase elevation could be caused by alcohol, medications (eg, NSAIDs, antibiotics, HMG-CoA reductase inhibitors, antiepileptic drugs, antituberculous drugs, herbal preparations), or viral agents. After thoroughly questioning the patient about his history and having him discontinue all alcohol and drug use, the next step in the evaluation process would be to repeat the liver function tests. If the transaminases persist in being elevated over a six-month period, they are categorized as chronic. Testing for viral hepatitis B and C, hemochromatosis, and fatty liver should then be undertaken to further evaluate chronically elevated transaminases. If these tests prove unremarkable, a search for muscle disorders (eg, polymyositis) and thyroid disease should be made. (Choice A) This patient has no obvious risk factors for viral hepatitis. Therefore, his drug and alcohol usage must be examined first. (Choice C) An ultrasound of the abdomen would not be particularly enlightening in a patient with asymptomatic aminotransferase elevation unless gallbladder pathology was suspected. (Choice D) These tests are employed to rule out Wilson's disease, which is not a likely diagnosis in an asymptomatic middle-aged man with an unremarkable history and physical exam. However, these tests could be ordered after all common causes of hepatitis were ruled out. (Choice E) These tests are employed to rule out hemochromatosis, which is a possible diagnosis in an asymptomatic middle-aged man with a normal physical exam. However, the more common causes of hepatitis should be ruled out before testing for the more unusual causes. Educational objective: In evaluating the asymptomatic elevation of aminotransferases, the first step is to take a thorough history to rule out the more common hepatitis risk factors (eg, alcohol or drug use, travel outside of the country, blood transfusions, high-risk sexual practices).

A 45-Year-Old Male Presents for a Routine Checkup Because He