Role Development in Family Practice: Clinical Integration

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Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states, “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested.

Past medical h story: Hypertension, dyslipidemia, hepatitis C.
Family history: Unremarkable
Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of illegal drugs, denies alcohol abuse, and has no tattoos.
Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily.
Allergies: No known drug or food allergies.
OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact. Vital signs: T: 96.8; P: 76; RR: 25; SaO 2 : 91; BP: 138/80. Her weight is 174 lb, and her height is 63 inches.
HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.
Cardiovascular: Regular rate and rhythm. Apical Pulse (PMI) is at 5th intercostal space, left sternal border. Pulses + 2 all extremities.
Respiratory: Lungs clear to auscultation, No wheezes; no crackles.
Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No organomegaly. No ascites.
Neurological: A & O × 4, CN II – XII grossly intact.
Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.
CRITICAL THINKING

Which diagnostic or imaging studies should be considered confirm the
diagnosis?
What is the most likely differential diagnosis?
What is your plan of treatment?
Are there any emergent referrals needed?

Sample Solution

Bertha’s presentation suggests a chronic hepatitis C infection based on her positive HCV antibody and elevated ALT levels. To confirm the diagnosis and assess the extent of liver damage, several diagnostic studies should be considered.

Diagnostic Studies

  1. HCV RNA test: This test detects the presence of the hepatitis C virus in the blood, confirming active infection.
  2. Liver ultrasound: To evaluate liver size, texture, and for any signs of cirrhosis or other abnormalities.
  3. Fibrosis assessment: This can be done using non-invasive methods like the FibroScan or blood tests (e.g., FibroTest, APRI).
  4. Complete blood count (CBC): To check for anemia, which can be associated with chronic liver disease.
  5. Coagulation studies: To assess for any bleeding or clotting abnormalities.

Differential Diagnosis

While chronic hepatitis C is the most likely diagnosis based on the presented information, other possibilities should be considered:

  • Non-alcoholic fatty liver disease (NAFLD): Elevated ALT levels can also be associated with NAFLD, especially in individuals with obesity or metabolic syndrome.
  • Autoimmune hepatitis: This autoimmune condition can cause liver inflammation and elevated liver enzymes.
  • Drug-induced hepatitis: Certain medications can cause liver damage.

Treatment Plan

If the HCV RNA test is positive, treatment with direct-acting antiviral agents (DAAs) is recommended. DAAs are highly effective and can cure hepatitis C in most cases. The specific treatment regimen will depend on the genotype of the HCV virus and the patient’s overall health.

Additional considerations:

  • Monitor for side effects: DAAs can sometimes cause side effects like fatigue, headache, or nausea.
  • Adherence to treatment: It’s important to adhere to the entire treatment course to achieve a cure.
  • Follow-up care: Regular monitoring of liver function and HCV RNA levels is necessary after treatment to ensure a cure.

Emergent Referrals

Based on the information provided, no emergent referrals seem necessary at this time. However, if Bertha develops symptoms of decompensated liver disease (e.g., ascites, jaundice, encephalopathy), immediate referral to a hepatologist would be required.

It’s important to note that this response is based on the limited information provided. A comprehensive evaluation by a healthcare provider is essential for a definitive diagnosis and personalized treatment plan.

 

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