hepatitis c
Doctor Information
Jose Fernandez, age 38
PMH:
Migraine
DH:
Sumatriptan 50 mg as required
No allergies
New patient to practice
Had health check 3 weeks ago with Nurse Karen Flannagan
Moved 6 months ago from Bolivia, has relatives in Yorkshire
Says no health problems except migraine, and rarely has to use sumatriptan
Non smoker, drinks 1-2 cans lager per night
Living with friends at present, unemployed but looking for work, ideally packing or handling in warehouse. BP 138/77
Bloods taken:
Hb 13.8
Wcc 5.7
Plt 408
U+E NAD
Alt 680
Alp 300
Bili 36
Chol 4.1
Results seen by Dr Frank, full liver screen requested:
Hepatitis B negative (antigen/antibody)
Hepatitits C positive (antibody and RNA)
Ferritin NAD
Caeruloplasmin NAD
Alpha-1-antitripsin negative
PMH:
Migraine
DH:
Sumatriptan 50 mg as required
No allergies
New patient to practice
Had health check 3 weeks ago with Nurse Karen Flannagan
Moved 6 months ago from Bolivia, has relatives in Yorkshire
Says no health problems except migraine, and rarely has to use sumatriptan
Non smoker, drinks 1-2 cans lager per night
Living with friends at present, unemployed but looking for work, ideally packing or handling in warehouse. BP 138/77
Bloods taken:
Hb 13.8
Wcc 5.7
Plt 408
U+E NAD
Alt 680
Alp 300
Bili 36
Chol 4.1
Results seen by Dr Frank, full liver screen requested:
Hepatitis B negative (antigen/antibody)
Hepatitits C positive (antibody and RNA)
Ferritin NAD
Caeruloplasmin NAD
Alpha-1-antitripsin negative
Patient Information
Jose Fernandez, age 38
History: You had a phone call to book this appointment for your blood results - apparently one of them came back abnormal.
If asked only: You came here 6 months ago from Bolivia because you wanted to have a better life in England. You worked for a taxi company in Bolivia but you were barely being paid, and your cousin and aunt live in the UK, so they suggested you come over. You are living with two friends that you met through gumtree (internet website) and you are doing interviews to get a job. You want to do some work in a warehouse with packing and moving, and eventually work as a HGV driver. You have gone on a few dates with a woman named Maria, and feel things are going well at the moment.
If specifically asked: you have no pain anywhere, no sickness or nausea, and no change in bowel habit. You have lost weight in the last few months but to be honest your finances are not great and you are probably eating less than you did previously. You do feel quite tired from day to day, even though you sleep well at night. There is no itching or skin changes. You have never used drugs and you do not smoke. You drink 1-2 cans of lager with your friends each night and have never had binges. You are heterosexual but single at the moment (although you have been on a few dates recently as above). You have not had any sexually transmitted infections in the past (ask the doctor why they want to know this if they ask). You were in a motorcycle accident 2 years ago in Bolivia and you did have to have 3 units of blood transfused. You do not know if blood is screened for infections there.
Ideas and concerns: you do not know which blood test is abnormal, but given that you have now had two different blood tests, you are worried that it might be something serious
Expectations: to be told you might need some treatment for something, or more tests
If the diagnosis of hepatitis is explained to you, you dont really understand why it is a big deal. It sounds like an infection, can you not just have some antibiotics for it? You start to get a bit more concerned if the doctor tells you that sometimes it cannot be cured, and can go on to damage your liver. You want to know how to stop it from doing this. You are also very disappointed that you can pass it on from sex, you are scared to tell Marie, she will leave you - what should you do about it? You will be ok if your questions are dealt with and you are made to feel like you will be well supported.
History: You had a phone call to book this appointment for your blood results - apparently one of them came back abnormal.
If asked only: You came here 6 months ago from Bolivia because you wanted to have a better life in England. You worked for a taxi company in Bolivia but you were barely being paid, and your cousin and aunt live in the UK, so they suggested you come over. You are living with two friends that you met through gumtree (internet website) and you are doing interviews to get a job. You want to do some work in a warehouse with packing and moving, and eventually work as a HGV driver. You have gone on a few dates with a woman named Maria, and feel things are going well at the moment.
If specifically asked: you have no pain anywhere, no sickness or nausea, and no change in bowel habit. You have lost weight in the last few months but to be honest your finances are not great and you are probably eating less than you did previously. You do feel quite tired from day to day, even though you sleep well at night. There is no itching or skin changes. You have never used drugs and you do not smoke. You drink 1-2 cans of lager with your friends each night and have never had binges. You are heterosexual but single at the moment (although you have been on a few dates recently as above). You have not had any sexually transmitted infections in the past (ask the doctor why they want to know this if they ask). You were in a motorcycle accident 2 years ago in Bolivia and you did have to have 3 units of blood transfused. You do not know if blood is screened for infections there.
Ideas and concerns: you do not know which blood test is abnormal, but given that you have now had two different blood tests, you are worried that it might be something serious
Expectations: to be told you might need some treatment for something, or more tests
If the diagnosis of hepatitis is explained to you, you dont really understand why it is a big deal. It sounds like an infection, can you not just have some antibiotics for it? You start to get a bit more concerned if the doctor tells you that sometimes it cannot be cured, and can go on to damage your liver. You want to know how to stop it from doing this. You are also very disappointed that you can pass it on from sex, you are scared to tell Marie, she will leave you - what should you do about it? You will be ok if your questions are dealt with and you are made to feel like you will be well supported.
Examination Findings
No jaundice
Pulse 67
Blood pressure 127/76
Abdomen soft, liver and spleen not palpable
Pulse 67
Blood pressure 127/76
Abdomen soft, liver and spleen not palpable
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation - makes blood borne virus risk assessment Identifies abnormal results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Encourages the patient to participate in appropriate health promotion particularly alcohol reduction |
NEGATIVE INDICATORS
Inappropriate or incorrect diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences Works with the patient to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Quick to judge |
Management
Explanation: Hepatitis C is a disease that is carried in the blood, and can damage the liver. Most often it is passed between people by sharing needles, having blood transfusions when the blood has not been checked for infections, or through sexual contact. Some people can clear the virus completely, while in other people it persists. There are treatments available for the infection, but come people will go on to have permanent liver damage.
Hepatitis C:
Is a RNA virus, which is thought to affect around 5 in 1000 in the UK. Risk factors for Hepatitis C are outlined below - it's important to ask about these when you're taking a Hep C history:
Hepatitis C:
Is a RNA virus, which is thought to affect around 5 in 1000 in the UK. Risk factors for Hepatitis C are outlined below - it's important to ask about these when you're taking a Hep C history:
- Hepatitis C is caused by a blood-borne virus, so people who have been exposed to another person's blood are most at risk.
- Sharing of injecting equipment and other drug paraphernalia
- Blood transfusions and blood products - Received blood in UK before 1991, or in certain other countries.
- Tattoos / piercings
- Household contact and sharing toiletry items
- There is a small theoretical risk from sharing items such as toothbrushes, razors, and other toiletry items that could be contaminated with blood.
- Needlestick injuries
- There is an estimated ~1% chance of a healthcare worker being infected with hepatitis C if they have a needlestick injury while treating a person who is infected with hepatitis C.
- Mother to baby transmission is considered to be a small, but possible, risk.
- 6% risk of mother - child transmission if active / chronic
- Transmission is not prevented by Caesarean section.
- Sexual transmission
- Countries where hepatitis C is endemic
- Procedures that pose a particular risk to the traveller include therapeutic injections, blood transfusions, haemodialysis, and surgical treatment.
Prognosis:
Of those who catch Hep C, 25% will clear it, and around 75% will go on to develop a chronic infection. Of those with a chronic infection most (80%) will go on to develop hepatitis. Those with hepatitis, are then at an increased risk of developing hepatocellular carcinoma or liver failure.
Diagnosis
Clinically it is difficult to diagnose hep C because the initial prodrome can be very similar to a normal viral illness. Screening those at risk is the usual method of picking up infection, or completing a liver screen in those with abnormal LFTs. A diagnosis of hep c is not only significant for health reasons, but will also affect insurance policies and mortgages.
Interpreting results can be stressful, especially when you are under pressure. With hep c, the antibody is checked first. If the antibody test is negative, then it may need repeating, especially if the first test is within the 'window' period of 3-6 months. A positive antibody test would then require a further blood test to check: HCV RNA. If positive the patient has active (chronic) hep c. If the antibody test is negative, they should have the test repeated again in 6 months time.[NICE CKS]
Management
Giving verbal and written information is the next step, explaining the progression, the need to get specialists involved, and that there are now treatments than can clear the infection in approximately 50% of people. The most important factor that affects disease progression is alcohol intake, and the patient should be strongly advised to avoid alcohol. Hep C can continue to be passed on, so the patient should avoid sharing personal items like razors, needles etc, and practice safe sex. Sexual contacts should be traced so they can also be screened. There is usually a protocol to refer these patients on to hepatology for assessment and treatment.
Whilst awaiting a referral to see the specialist, it may be wise to request some further tests including: HIV screen, Hepatitis A, Ferritin, Glucose and repeat LFT's
Of those who catch Hep C, 25% will clear it, and around 75% will go on to develop a chronic infection. Of those with a chronic infection most (80%) will go on to develop hepatitis. Those with hepatitis, are then at an increased risk of developing hepatocellular carcinoma or liver failure.
Diagnosis
Clinically it is difficult to diagnose hep C because the initial prodrome can be very similar to a normal viral illness. Screening those at risk is the usual method of picking up infection, or completing a liver screen in those with abnormal LFTs. A diagnosis of hep c is not only significant for health reasons, but will also affect insurance policies and mortgages.
Interpreting results can be stressful, especially when you are under pressure. With hep c, the antibody is checked first. If the antibody test is negative, then it may need repeating, especially if the first test is within the 'window' period of 3-6 months. A positive antibody test would then require a further blood test to check: HCV RNA. If positive the patient has active (chronic) hep c. If the antibody test is negative, they should have the test repeated again in 6 months time.[NICE CKS]
Management
Giving verbal and written information is the next step, explaining the progression, the need to get specialists involved, and that there are now treatments than can clear the infection in approximately 50% of people. The most important factor that affects disease progression is alcohol intake, and the patient should be strongly advised to avoid alcohol. Hep C can continue to be passed on, so the patient should avoid sharing personal items like razors, needles etc, and practice safe sex. Sexual contacts should be traced so they can also be screened. There is usually a protocol to refer these patients on to hepatology for assessment and treatment.
Whilst awaiting a referral to see the specialist, it may be wise to request some further tests including: HIV screen, Hepatitis A, Ferritin, Glucose and repeat LFT's