DIALOGUE

[patient] hey bruce so see here my my notes here is you here he had positive lab work for hep c so how're you doing today
[doctor] i'm doing okay but i'm a little bit anxious about having hep c i've really surprised because i've been feeling fine they had done it as you know a screen as just part of my physical so i'm really surprised that that came back positive
[patient] okay so in the past have any doctors ever told you that you had hep c
[doctor] no never that's why i'm i'm so surprised
[patient] okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners
[doctor] i mean i used to party a lot and even did use iv drugs but i have been clean for over fifteen years now
[patient] okay that that's good i mean i'm i'm happy that you were able to to kick that habit i know a lot of my patients that i see you know they're still dealing with with those dements so i'm i'm i'm happy that you're able to do that so hopefully we can get you better okay
[doctor] thank you
[patient] so what about alcohol use is that something that you used to do a lot
[doctor] i did i did i mean i i still have a beer here and there everyday but not as much as i used to
[patient] okay and have you ever smoked before
[doctor] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too
[patient] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well
[doctor] okay
[patient] so do you have any other medical conditions
[doctor] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise
[patient] okay and what conditions would you say run in your family
[doctor] i have high blood pressure diabetes and depression
[patient] okay
[doctor] alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate
[patient] regular rate and rhythm with a grade two out of six systolic ejection murmur is appreciated on your lung exam your lungs are clear without wheezes rales or rhonchi on your abdominal exam bowel sounds are present your abdomen is soft with no hepatosplenomegaly
[doctor] hepatosplenomegaly yes let me i will change that one
[patient] splenomegaly and on your muscle exam there is no gait disturbance or edema so i did we i was able to review your your results of your recent lab work and your hcv antibody test was positive so your your liver panel we did one of those and it showed an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so that's pretty good so let's talk a little bit about my assessment and plan for you so you do have hepatitis c so your initial labs were consistent with that hep c diagnosis and so you know i do n't know if you read much about hep c but hepatitis c is a viral infection that does affect your liver and you've most likely had it for several years now it it it most patients do n't see symptoms until years later so the next step that i would like to do is just confirm the diagnosis with some additional blood work so that includes checking your hep c rna and your hcv genotype and i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and we will do that by ordering an ultrasound elasto elastography with this information we will we we will be able to know how we can proceed as far as treatment right so how does that sound
[doctor] i hmmm so i do have a wife and kids so should i be worried about them
[patient] okay yeah so we can start with the same screening that you had for august first so we'll just let's do that hep c antibody test and i'll actually help you set up those appointments with your your family doctor and then we can just see you back in three weeks and based on the results you know we will take action as needed okay
[doctor] okay that sounds good
[patient] alright
[doctor] alright
[patient] my nurse will be in with those those orders
[doctor] alright thank you
[patient] alright thanks
[doctor] bye

CLINICAL NOTE

CHIEF COMPLAINT

Hepatitis C.

HISTORY OF PRESENT ILLNESS

Bruce Ward is a pleasant 60-year-old male who presents to the clinic today following a positive result in a hepatitis C antibody test. He was sent to obtain the hepatitis C antibody test as part of a routine physical. He states he is anxious with the results and denies he has ever been diagnosed with hepatitis C. The patient admits to intravenous drug use in the past; however, he notes it has been longer than 15 years since his last usage. He also reports a history of heavy alcohol use. He continues to drink a beer on occasion. The patient currently smokes 1 to 2 cigarettes per day. He notes he used to smoke more and is having difficulty with complete cessation.

MEDICAL HISTORY

The patient denies any significant past medical history.

SOCIAL HISTORY

The patient is married with children. He reports history of IV drug use 15 years ago. He currently drinks beer occasionally. The patient reports smoking 1 to 2 cigarettes per day.

FAMILY HISTORY

He reports a family history of high blood pressure, diabetes, and depression.

MEDICATIONS

Patient denies taking any current medications.

VITALS

All vital signs are within normal limits.

PHYSICAL EXAM

CONSTITUTIONAL: In no apparent distress.
CV: Regular rate and rhythm. Grade 2 out of 6 systolic ejection murmur is appreciated.
RESPIRATORY: Lungs are clear without wheezes, rales, or rhonchi.
GI/GU: Abdomen is soft with no hepatosplenomegaly. Bowel sounds are present.
SKIN: No jaundice.

RESULTS

The HCV antibody test was reviewed today and is positive.

Liver panel revealed an elevated AST at 39 U/L. The ALT, albumin, and total bilirubin were all within normal limits.

ASSESSMENT

Hepatitis C.

PLAN

After reviewing the patient's laboratory findings today, I have had a lengthy discussion with him in regard to his current symptoms. His initial labs were consistent with a hepatitis C diagnosis. I have recommended that we confirm the diagnosis with additional blood work including checking his hepatitis C RNA and HCV genotype. I have also recommended that we obtain an ultrasound elastography to evaluate for fibrosis of the liver.

The patient is married with children and is concerned about their hepatitis C status. I advised the patient that his family should be screened and we will assist him with setting appointments with their primary care physician.

INSTRUCTIONS

The patient will follow up with me in 3 weeks to review his results and discuss further treatment.