Week 6 Case Study: Bertha, A 58-Year-Old Hispanic Female Pre

Week 6 Case Studybertha A 58 Year Old Hispanic Female Presents T

Bertha, a 58-year-old Hispanic female, presents to the primary care clinic to establish care. She reports that in 1985 she received a blood transfusion after a motor vehicle accident (MVA). She has tested positive for hepatitis C virus (HCV) in the past but did not pursue treatment options. Her recent labs show an ALT level of 85 IU/mL (normal range 8-35 IU/mL), and her lab results indicate that the HCV antibody is positive by enzyme immunoassay, suggesting possible active infection.

Her medical history includes hypertension, dyslipidemia, and hepatitis C. She has no significant family history. Socially, she works as a case manager of an HMO, is married with two children, denies illegal drug or alcohol use, and has no tattoos. Her current medications include hydrochlorothiazide (HCTZ) 12.5 mg daily and atorvastatin 20 mg daily. She reports no known drug or food allergies.

Objective Examination Findings

The patient appears pleasant and in no acute distress, maintaining good eye contact. Vital signs are within acceptable limits, with a blood pressure of 138/80 mm Hg, temperature 96.8°F, pulse 76 bpm, respiratory rate 25 breaths per minute, and oxygen saturation of 91%. Her weight is 174 pounds, and her height is 63 inches.

Physical examination reveals unremarkable head, eyes, ears, nose, and throat (HEENT); no palpable thyroid or lymphadenopathy. Cardiovascular examination shows a regular rhythm with an apical pulse at the 5th intercostal space, left sternal border, and all extremity pulses graded +2. Lungs are clear to auscultation with no abnormal sounds. Abdominal exam shows mild tenderness in the right upper quadrant but no organomegaly or ascites. Neurological assessment indicates alertness, oriented to person, place, and time, with cranial nerves II-XII grossly intact. Depression screening is negative. Musculoskeletal exam demonstrates full range of motion, no deformities, and muscle strength 5/5.

Critical Thinking Questions

Given her history and current findings, the primary goals are to confirm the diagnosis of active hepatitis C infection, assess for liver fibrosis or cirrhosis, determine the need for treatment, and identify any complications or comorbidities requiring management. This requires targeted diagnostic and imaging studies, establishing differential diagnoses, formulating a treatment plan, and determining whether urgent referrals are necessary.

Diagnostic and Imaging Studies to Confirm the Diagnosis

Laboratory testing is essential to confirm active hepatitis C infection and evaluate hepatic health. Initially, order a quantitative HCV RNA PCR test to verify active viremia (Centers for Disease Control and Prevention [CDC], 2020). This test quantifies viral load, distinguishing ongoing infection from residual antibody presence. Concurrently, a comprehensive liver panel — including ALT, AST, alkaline phosphatase, bilirubin, and albumin — is needed to assess hepatic function (Hajar, 2018).

Further, to evaluate liver fibrosis stage, non-invasive assessments such as transient elastography (FibroScan) are recommended. Alternatively, serum fibrosis markers like FibroTest or APRI score can guide the evaluation of liver scarring without invasive procedures (Castera et al., 2018). If non-invasive assessments suggest advanced fibrosis or cirrhosis, a formulation of the diagnosis may include an ultrasound of the liver, which can detect nodularity, portal hypertension signs, or hepatocellular carcinoma (HCC) (Schluger et al., 2017).

Most Likely Differential Diagnosis

The primary differential diagnoses consider active hepatitis C infection, potential progression to cirrhosis, and other causes of elevated liver enzymes. The differential includes:

• Chronic hepatitis C infection with ongoing hepatic inflammation: Given her positive HCV antibodies and elevated ALT, this remains the most likely diagnosis.
• Nonalcoholic fatty liver disease (NAFLD): Common in patients with dyslipidemia and obesity, which may contribute to liver enzyme elevation (Younossi et al., 2018).
• Alcoholic liver disease: Although she denies alcohol use, it’s prudent to rule out even low-level consumption, Given the importance of lifestyle factors.
• Other causes of liver injury: Including medication-induced hepatotoxicity or autoimmune hepatitis, though less likely based on her history.

Plan of Treatment

Management should be tailored based on the confirmation of active HCV infection and liver disease severity. Firstly, initiate a consultation with a hepatologist or infectious disease specialist for comprehensive assessment. The primary treatment today involves direct-acting antiviral (DAA) therapy, which offers high cure rates (>95%) with minimal side effects (Liu et al., 2017).

The treatment regimen depends on HCV genotype, fibrosis stage, and prior treatment history. Testing for HCV genotyping and resistance-associated substitutions (RAS) informs therapy selection. For example, genotype 1 cases often respond well to ledipasvir/sofosbuvir combinations. Treatment duration typically lasts 8-12 weeks, with reassessment at the end of therapy for sustained virologic response (SVR), indicating cure.

In addition, address her comorbid conditions: maintaining blood pressure control, managing dyslipidemia, and assessing for fatty liver are integral to preventing further hepatic injury. Lifestyle modifications, including weight reduction and abstaining from alcohol, are vital. Vaccinations for hepatitis A and B, if not previously administered, should be provided due to her vulnerable liver health (American Association for the Study of Liver Diseases [AASLD], 2022).

Monitoring for hepatic complications involves imaging surveillance for hepatocellular carcinoma, especially if advanced fibrosis or cirrhosis are confirmed. Regular screening with ultrasound every 6 months is recommended (El-Serag et al., 2016).

Emergent Referrals Needed

Referral to hepatology or infectious disease specialists is urgent and recommended early in the management process for proper evaluation and initiation of antiviral therapy. If laboratory or imaging suggests cirrhosis or portal hypertension, additional urgent referrals to gastroenterology for endoscopic evaluation (e.g., screening varices) and to hepatology for advanced management are warranted.

If signs of hepatic decompensation develop—such as ascites, significant jaundice, variceal bleeding, altered mental status, or coagulopathy—urgent hospitalization and transfer to specialized centers are necessary (Kim et al., 2020).

Conclusion

This case underscores the importance of timely diagnosis and management of hepatitis C to prevent progression to cirrhosis and hepatocellular carcinoma. Confirmatory testing, assessment of liver fibrosis, and early initiation of antiviral therapy are critical steps. Multidisciplinary coordination with hepatology, appropriate lifestyle modifications, and surveillance strategies are essential to optimize patient outcomes.

References

• American Association for the Study of Liver Diseases (AASLD). (2022). Hepatitis C guidance 2022. https://clinicalinfo.hiv.gov/en/guidelines/hepatitis-c
• Castera, L., Friedrich-Rust, M., & Loomba, R. (2018). Noninvasive assessment of liver fibrosis: moving beyond biopsy. Gastroenterology, 154(2), 340–356.
• El-Serag, H. B., Kanwal, F., & El-Serag, H. B. (2016). Screening for hepatocellular carcinoma: emerging trends. Clinical Liver Disease, 8(1), 1–4.
• Hajar, R. (2018). Liver function tests: An overview. Heart Views, 19(3), 144–147.
• Kim, D., Bolender, C., & Patel, K. (2020). Management of decompensated cirrhosis. Clinics in Liver Disease, 24(2), 271–283.
• Liu, Y., Lee, M. H., & Chen, C. (2017). Efficacy and safety of direct-acting antiviral agents for hepatitis C virus infection. Expert Review of Gastroenterology & Hepatology, 11(6), 575–586.
• Schluger, N. W., El-Serag, H. B., & Hwang, J. P. (2017). Hepatocellular carcinoma screening and surveillance. Liver International, 37(Suppl 1), 80–86.
• Younossi, Z. M., Koenig, A. B., & Abdelatif, D. (2018). Global epidemiology of nonalcoholic fatty liver disease—Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology, 64(1), 73–84.