# A nurse is assessing a 35-year-old patient who recently returned from international travel. Which assessment finding would be MOST indicative of hepatitis A infection in the early prodromal phase?

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> subject: Infectious Diseases

## 문제

A nurse is assessing a 35-year-old patient who recently returned from international travel. Which assessment finding would be MOST indicative of hepatitis A infection in the early prodromal phase?

## 보기

1. Presence of spider angiomata and palmar erythema
2. Dark amber-colored urine with clay-colored stools
3. Severe right upper quadrant pain with rebound tenderness
4. Flu-like symptoms with fatigue, nausea, and low-grade fever **✔ 정답**

**정답: 4**

## 해설

Flu-like symptoms are most indicative of early prodromal hepatitis A. Other findings like jaundice or pain occur later in the disease course.

## 심화 해설

Clinical Phase Recognition in Hepatitis A

The question targets the prodromal (pre-icteric) phase of hepatitis A virus (HAV) infection. Understanding the timeline of viral hepatitis is critical for early identification and isolation. Hepatitis A typically progresses through distinct stages: an incubation period, a prodromal phase, an icteric phase, and convalescence. The prodromal phase occurs after the incubation period and immediately before the onset of jaundice. During this time, the virus is actively replicating in the liver, triggering a systemic immune response, but bilirubin levels have not yet risen sufficiently to cause visible jaundice. Consequently, the clinical picture is dominated by constitutional symptoms rather than signs of cholestasis or chronic liver disease.

Why Flu-Like Symptoms Define the Prodromal Phase

Option 4 describes flu-like symptoms with fatigue, nausea, and low-grade fever. This presentation is the hallmark of the prodromal phase of acute viral hepatitis. The pathophysiology stems from viremia and the cell-mediated immune response against infected hepatocytes, which releases pyrogens and inflammatory cytokines. This systemic reaction manifests as malaise, anorexia, nausea, and a temperature typically around 100–102°F (37.8–38.9°C). The cited case report, while focused on a severe pediatric complication, reinforces that HAV is an acute infection that can cause significant systemic illness. In the early stages, before the development of specific hepatic complications like the severe derangements and bleeding described in the source [1], the presentation is often nonspecific and resembles a viral syndrome. Recognizing this phase is a key nursing assessment point, as a patient with these symptoms and a relevant travel history must be promptly isolated and tested.

Distinguishing from Other Hepatic Manifestations

The other options represent findings from different stages or different disease processes entirely, making them incorrect for the early prodromal phase of HAV.

- **Option 1 (Spider angiomata and palmar erythema):** These are cutaneous signs of chronic liver disease and hyperestrogenism, typically seen in cirrhosis, not in the acute, self-limiting course of hepatitis A.

- **Option 2 (Dark amber-colored urine and clay-colored stools):** This is the classic presentation of the icteric phase. It occurs when bilirubin excretion is obstructed due to hepatocyte swelling, causing conjugated bilirubin to spill into the urine (darkening it) and a lack of stercobilin in the stool (making it clay-colored). This phase follows the prodromal phase.

- **Option 3 (Severe right upper quadrant pain with rebound tenderness):** Rebound tenderness is a sign of peritoneal inflammation. While hepatomegaly can cause a dull ache in the right upper quadrant, severe pain with rebound tenderness is not typical for uncomplicated acute viral hepatitis and would necessitate immediate evaluation for a surgical abdomen, such as cholecystitis or a hepatic abscess.

The case report details a child who developed a life-threatening duodenal ulcer bleed in the context of acute HAV with severe hepatic derangements [1]. This underscores that while complications can occur, they are not the defining feature of the initial prodromal presentation. The nurse's initial assessment must first identify the flu-like prodrome to trigger appropriate diagnostic testing and precautions.

References (research sources)

- [1]Life-Threatening Gastrointestinal Bleeding in a Child with Acute Hepatitis A.Research articleZlatanova S, Hristamyan M, Ketev K. (2026) · DOI: 10.3390/children13040526

## 임상 시나리오

Clinical Guidance: Early Recognition of Hepatitis A

**Prodromal Presentation:** The earliest symptomatic phase of Hepatitis A is marked by non-specific, flu-like symptoms. Patients typically present with fatigue, malaise, anorexia, nausea, vomiting, and a low-grade fever (37.8–38.9°C). Right upper quadrant discomfort may be present but is usually mild. This phase lasts 3 to 10 days and precedes the onset of jaundice.

Key Assessment Findings

- **Systemic:** Fever, profound fatigue, myalgias.

- **Gastrointestinal:** Nausea, vomiting, diarrhea, anorexia, altered taste.

- **Hepatic:** Mild, dull right upper quadrant pain; liver may be slightly tender on palpation.

Differential Diagnosis

- **Influenza or Viral Syndrome:** Differentiated by epidemiological risk factors (travel to endemic areas, known exposure, foodborne outbreaks) and subsequent development of jaundice.

- **Other Viral Hepatitis (B, C):** Similar prodromal symptoms but different incubation periods and risk factors (parenteral exposure).

Nursing Actions

- Obtain a detailed travel and dietary history, including ingestion of raw shellfish or untreated water.

- Implement contact precautions and strict hand hygiene, as the virus is shed in stool during the prodromal phase.

- Monitor for progression to the icteric phase: onset of dark urine, clay-colored stools, and scleral icterus.

- Educate the patient on the importance of rest, hydration, and avoidance of alcohol and hepatotoxic medications.

## 핵심 개념

- **Prodromal Phase** — The early stage of an infection characterized by non-specific constitutional symptoms such as fatigue, fever, and nausea, occurring before the classic signs of the disease appear.
- **Icteric Phase** — The stage of hepatitis where bilirubin levels rise, leading to visible jaundice, dark urine, and clay-colored stools.
- **Spider Angiomata** — A vascular lesion with a central arteriole and radiating branches, associated with hyperestrogenism in chronic liver disease.

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