Follow Up | Test Discussion | Hepatitis A

Casebank Counselling
1

Where you are:
You are working as a Foundation year two doctor in general practice. (GP Surgery)

Who the patient is:
Your next patient is a 33 years old woman Joan Smith who had presented to your practice 1 week ago and had blood tests done.

Other information you have about patient:

ALT – 530 (5-35)
AST – 110 (5-35)
ALP – 83 (30-150)
Bilirubin – 35 (3-17)
GGT : Normal

What you must do:
Explain the results, take a focused history and discuss initial management with the patient.

Special Note:
None

Patient Information

  • You are Mrs .Joan Smith, a 33 year old lady.
  • You had come to see your GP last week because you have been feeling tired and lethargic for the past 3 weeks.
  • You have also been experiencing dull achy pain on the right upper side of your tummy which is 4/10 in severity.
  • You have also noticed some yellowish discolouration of your eyes.
  • You felt sick but you did not vomit, you have pain on the right upper quadrant.
  • You are sexually active with your husband
  • You have been married for the past 10 years
  • You do not use condoms
  • You like eating out (in restaurants) most of the times with your husband
  • Eats at the restaurant 3 times in a week
  • Your favourite dish is seafood oysters and shell fish and you ate there prior to the onset of symptoms.
  • Your husband dos not have any of these symptoms, he does not like to eat seafood.

SCENARIO B

  • You still have symptoms of tummy pains on the right hypochondrium
  • Feeling nausea and vomitng from time to time
  • Still having loose stools

Questions:

  • Why are my liver enzymes high?
  • What’s bilirubin?
  • What’s wrong with me?
  • Why do I have this infection?
  • What are you going to do for me?
  • Was it the shell fish that caused this?
  • I won’t go to that restaurant again.
  • Is “hepatitis A” a serious condition?
  • How did I get this infection?
  • What will you do?

EXAMINER’S PROMPT:

  • If candidate requests observations, say observations are normal.
  • If candidate requests to do a tummy exam, say tenderness in right upper quadrant of abdomen.
  • If candidate requests Abdominal ultrasound, say USS normal.
  • If candidate request to do a hepatitis screening, say IGM is positive.

SETUP

  • 2 seats for patient and doctor, examiner siting and observing directly.
  • LFT RESULTS are available on the table in the cubicle.
  • Once you pick the result, the patient comes closer interested in knowing her result.

Emotions and Attitude: Just calm and normal

Approach 1

GRIPS, shake hands, smile

Paraphrase

History - Any particular reason for the blood test?

  • History of the symptoms
  • Fever, nausea, vomiting, pale stools, diarhhoea, jaundice, abdominal pain, dark urine, pale stools
  • Systemic review
  • P3MAFTOSA
  • Travel & alcohol history
  • Genetic history
  • Sexual history
  • What kind of diet do you like?
  • What do you normally eat?
  • Do you normally wash fruit before eating?
  • Do you eat out normally?
  • Where do you eat out?
  • Who do you normally go out with?
  • Does he like to eat the same food as you?
  • Have you traveled abroad recently?
  • D/Ds –Hep A, B, C

Pause
Explain the results to the patient (show him the results while explaining) and explain that “unfortunately, there is a little bit of damage”

Management

  1. Explain the diagnosis is likely to be hepatitis A
  2. Observations (BP, pulse, temp, respiratory rate) + Abdominal examination + PR examination
  3. Hepatitis screen.

Approach 2

Questions:

  1. what could it be doctor?
  2. how will you manage me?
  3. what is wrong with me?
  4. What are you going to do for me?

  1. Paraphrase - I understand…
  2. Check if the results have been explained to him
  3. Reason for the blood test done three weeks ago
  4. Explain results: Explain that the bloods were done to check if the liver is functioning and it shows that there is damage going on in the liver.
  1. History: I was wondering what is the cause of the problems. I would like answers please.
    Take history:
    • History of presenting complaints even if this was 3 weeks ago.
    • Differential Diagnosis
    • MAFTOSA
    • ICE
  1. Explain it is difficult to say what is the cause for the tummy pains so and that you would like to examine his tummy, check his observations: Temperature, RR, BP, oxygenation).
  2. Abdominal examination: Examiner will tell you, “doctor there is tenderness on the right hypochondrium”
  3. Explain the Diagnosis:
    • One of the causes for the changes in the blood test is hepatitis infection, in particular a type of hepatitis infection called Hepatitis A is one of the most common cause of these type changes in the blood tets.
    • It is usually contacted by eating sea foods like sea shells. Very commonly if you have been eating in restaurants.
    • So I would like to perform Hepatitis screen tests. And If it is Hepatitis A, it is usually resolves on its own after few weeks. But there are other types of hepatitis infections which we need to rule out as well as completely different causes of damage to the liver.
    • Apply ICE: Ask if there is anything in particular patient is worried about.

Investigations

  • hepatitis screen,
  • Advice to avoid alcohol if the patient drinks.
  • But you would offer supportive (analgesia, anti-emetic, avoid paracetamol)
  • Advice to repeat blood tests in one month a time.
  • Usually blood tests would normalise or show tendency be returning back to normal
  • Repeat the liver function tests in 1-month time to see if blood tests will come back to normal.
  • If it is not back to normal in 1 month time then we will do an ultrasound scan and we will as well refer you to a specialist ( gastroenterologist).

PROGNOSIS

  • If it is what we are suspecting (hepatitis A infection) usually it resolves within 2 months weeks and the blood test usually return back to normal

Summarize: Just to go through the main points:

  • So we have discussed that that there is some damage to liver, which are likely to be due to hepatitis A infection but we need to rule out other types of hepatitis infections like Hepatitis B and C which can cause the same changes of blood tests.
  • And we discussed that we will be doing some more blood tests to check for infections as well as an ultrasound scan of the liver to help us rule out other causes.
  • And I hope I have managed to reassure that even if there are a lot more causes for the same changes in your blood tests the most likely cause of this these changes which is likely to resolve on its own.
2

You are FY2 in GP clinic.

A 38-year-old woman came to the GP clinic for her blood results. Please take focused history and manage her accordingly.

Blood results:
increased ALT [ ALT> AST]
Increased AST
Increased Bilirubin
Normal GGT and ALP

Station flow:

  • Chief complaint: Tummy pain for 2 weeks: on and off
  • Loose motion: 3 to 4 episodes per day
  • Mild fever- on and off for 2 weeks.
  • No travel history.
  • No significant past medical history.
  • DESA- Likes to eat uncooked clam from a restaurant.

Concerns: When can I go for work?

Management

  • Admit any person with hepatitis A infection to hospital if they are severely unwell, for example, with vomiting, dehydration, or signs of hepatic decompensation.
  • If hospital admission is not required, provide supportive symptomatic care as required:
  • Advise the person to rest when necessary, and stay hydrated.
  • If pain relief is required, options include:
    • Ibuprofen — prescribe with caution in mild to moderate hepatic impairment and avoid in severe hepatic impairment.
    • Paracetamol — caution is advised with the use of paracetamol in people with acute hepatitis due to increased risk of toxicity — avoid if possible.
    • Weak opioids (such as codeine) — prescribe with caution in mild liver impairment and avoid in severe hepatic impairment (due to enhanced sedative effects and reduced drug clearance).
  • If treatment of nausea is required, options include:
    • Metoclopramide (for people aged over 20 years for a maximum duration of 5 days of treatment) or cyclizine, if liver impairment is mild.
  • If treatment of itch is required, options include:
    • Simple measures (such as maintaining a cool, well-ventilated environment, wearing loose clothing, and avoiding hot baths or showers).
    • Chlorphenamine at night — avoid in severe liver impairment.
  • Seek specialist advice on the choice and dosage of analgesic, anti-emetic, or anti-pruritic if the person has more severe hepatic impairment or symptoms are difficult to manage.
  • Withhold potentially hepatotoxic drugs – seek specialist advice if unsure.
  • Notify the local Health Protection Unit (HPU) promptly to facilitate appropriate surveillance, contact tracing, and initiation of preventative measures for close contacts.
  • If an outbreak is suspected, or the person is a food handler or staff in residential care, notify the HPU immediately. On confirmation of infection the health protection team will ask the person to complete a Hepatitis A: case questionnaire.
  • Provide the person with information and advice about hepatitis A. In particular, advise them to:
  • Avoid drinking alcohol, as this can increase the risk of liver damage.
  • Avoid work, school, or nursery until they are no longer infectious (typically 7 days after the onset of jaundice, or 7 days after the onset of symptoms; such as fatigue, nausea, or fever, if there is no history of jaundice).
  • Take steps to minimize the risk of transmission to partners and contacts. The person and all close contacts should:
  • Ensure thorough hand washing after using the toilet, including supervising young children who may have difficulty with personal hygiene.
  • Wash their hands immediately after changing nappies or helping with child toileting (including handling a potty).
  • Ensure good general personal hygiene.
  • Avoid handling food, if possible, or ensure thorough hand washing before food preparation, for contacts of cases.
  • Avoid unprotected sexual intercourse, including oro-anal and oro-genital contact, until the person is no longer infectious (typically 7 days after the onset of jaundice, or 7 days after the onset of symptoms if there is no history of jaundice).
  • Avoid sharing needles and other drug paraphernalia

Literature