Hepatitis C Case Study: Lab Interpretation for New Grad NPs

GILab Interpretation

Jan 6

Written By Liz Rohr

Watch

Show notes:

Diagnosing hepatitis C is actually super simple, but can trip up new (and experienced!) nurse practitioners.

You may think: "I'm in primary care, do I need to know that?"

It comes up more often than you think. Like when you inherit a patient whose last plan of care for his Hepatitis C is "continue to monitor."

Monitor what? Have they gotten treatment? Do they need to?

Hepatitis C Lab Interpretation Case Study

I got you. Using in a case study, I'll walk you through step-by-step:

Which labs to order (and what they mean)
Who needs treatment (and who doesn't...yet)
How to monitor patients with Hep C (especially when they don't want to go to GI)
The next steps depending on your results, and when to refer to GI

PLUS, download a cheat sheet below to keep at your desk for quick reference.

Hepatitis C Lab Interpretation Cheat Sheet

If you’re looking for the Hepatitis C Cheat Sheet it’s inside the Digital NP Binder! Purchase yours here!

Want to Build More Confidence Interpreting Labs?

If you found this case study helpful, you'll probably enjoy the Lab Interpretation Series.

Inside the series, we take the same practical, case-based approach to interpreting common primary care labs—but go much deeper into the clinical reasoning behind them. Rather than memorizing reference ranges, you'll learn how to recognize patterns, work through differential diagnoses, and apply lab results to real patient care.

The Lab Interpretation Series includes self-paced, ANCC-accredited courses covering CBC, basic metabolic panel, renal labs, liver function tests, thyroid labs, hyperlipidemia, and more.

Learn more about the Lab Interpretation Series →

If you liked this post, also check out:

0:00
if you find yourself confused by
0:01
hepatitis C both the labs to order how
0:03
to interpret them and then your role as
0:05
a PCP this video is all about that if
0:07
you're new here I'm Liz Rohr from real
0:09
world and P and you're watching and free
0:11
practice means simple the weekly videos
0:13
to help save you time frustration and
0:14
help you learn faster so you can take
0:16
the best care of your patients so also
0:18
included in this video is going to be a
0:19
cheat sheet so definitely download it
0:21
below this video
0:22
print it out keep it at your desk for
0:23
quick reference got some great extra
0:25
resources too if you want to learn more
0:27
also if you're if you're on a lab
0:29
interpretation journey if you'd like to
0:31
join us for the lab interpretation crash
0:33
course for new nurse practitioners it
0:35
opens next week and I'm so excited so if
0:38
you're interested to get on the wait
0:40
list to get emails about that it's
0:41
real-world 2np comm slash labs and then
0:44
I'll give you all the details there
0:45
without further ado though I'm gonna
0:47
share my screen with you so this is the
0:49
Hep C case study so this is John he's 32
Case Study
0:52
year old man he's a new patient to the
0:54
clinic it's not his real name or his
0:55
phone out so he's assumption care with a
0:58
new PCP he hasn't seen a doctor in 10
1:00
years I don't know if you seen this come
1:02
up I see this come up quite a bit
1:04
he wants to quote get tested for
1:06
everything this is chief complaint and
1:08
typically when I see this not to
1:10
typecast but I think typically when I
1:12
see this there's really more going on to
1:13
the story then patients are kind of
1:15
willing to to you know a volunteer at
1:19
the time so I tend to treat those those
1:21
visits it kind of gently and just making
1:23
sure that I'm being really sensitive to
1:24
is there anything underlying that it's
1:27
kind of like the real story of what's
1:28
going on so he's a current smoker he's
1:31
smokes one pack a day he formerly used
1:34
nasal cocaine with occasional IV heroin
1:37
use he's still kind of using here and
1:39
there but trying to get a history I try
1:41
to ask these questions and if you want
1:43
me to get into this more in terms of
1:44
obtaining a history I'm definitely happy
1:46
to but I try to be very open and
1:48
non-judgmental things like okay so like
1:50
when was the last time you used heroin
1:52
like are you still using right now is it
1:54
like everyday a couple of times a day
1:55
kind of like you know bringing it from
1:57
the offering the scenarios that they
2:00
probably would be embarrassed to admit
2:01
that most patients are embarrassed to
2:02
admit and kind of taking it down from
2:04
there because most patients most most
2:06
patients will happily volunteer oh no no
2:08
I just used heroin like one time like
2:09
last month that kind of thing so anyway
2:12
let me know if you want me to talk more
2:13
about that
2:14
he has no current sexual partners but he
2:16
quote dates and again Kiki wasn't really
2:18
forthcoming with this history either and
2:20
I had to do a little bit of kind of
2:22
asking it a couple different ways to get
2:23
some information but it is what it is
2:25
and sometimes that's just what happens
2:26
when when at least for me when I get
2:28
patients and they first come in and they
2:29
don't really want to disclose they
2:31
haven't been in health care for about
2:32
ten years they don't really want to get
2:34
into some stuff they just really want to
2:35
get the answers that they're looking for
2:36
so no no family history a past surgical
2:40
history past medical history he doesn't
2:42
take any medications blood pressure is
2:44
normal 130 over 70 our rate of 70 oxygen
2:46
and respiratory rate are normal and his
2:48
BMI is also normal 22 so plan I'm going
2:50
to be talking about Hep C in this
2:52
particular video but I'm going to touch
2:55
on the other components of his holistic
2:56
care at the end so um well one kind of
3:00
minor note is that I'm trying to as I
3:03
progress in my career think about I
3:06
think that in general and in this
3:08
country we over test non-us and I think
3:11
a lot of new nurse practitioners really
3:12
worried about that ordering too many
3:13
tests and I think it's something that
3:14
you can be mindful of but don't stress
3:16
out too much about especially if you're
3:18
brand new or if you're still a student
3:19
because that's kind of how we all
3:21
progress and how we all learn but I'm
3:23
trying to be more mindful of it and
3:24
really make really make solid decisions
3:27
about when to test labs for people and
3:29
when not to and I still feel conflicted
3:30
about it I don't feel great but there's
3:31
no real guidelines about ordering like a
3:33
a CMP or a CBC for this patient so
3:36
really I focused on his risk factors and
3:38
so I only tested for him Hep C antibody
3:40
is HIV because he has risk factors of IV
3:44
drug use which I'm going to talk about
3:45
in a second Hep B service antigen and
3:47
antibody if you haven't watched the Hep
3:48
B lecture definitely go back and do that
3:50
that was last week what kind of help you
3:52
feel comfortable with those labs but
3:54
just looking for that because I wasn't
3:56
able to get like a clear history in
3:59
terms of a sexual history about condom
4:01
use and how many partners and and who
4:03
his partners are and things like that
4:05
um syphilis testing are PR because it's
4:08
one of those sexually transmitted
4:09
infections it's a more it's on the rise
4:11
there are certain populations where it's
4:12
on the rise more so than others but I
4:15
believe that IV drug use kind of also
4:17
predisposes you to that and then
4:19
gonorrhea and chlamydia I have a star
4:20
here because really I actually could do
4:23
a whole video about sexual health
4:24
history and testing and I'd love to go
4:27
into that but I'm
4:28
little worried about getting censured by
4:29
YouTube so I'm not gonna get into it
4:30
super a lot right now
4:32
but you really want to make sure you're
4:33
you're testing all the sites of exposure
4:35
not just a urine sample and so really
4:39
getting a good history about that with
4:41
your patience and kind of who their
4:42
sexual partners are and and things like
4:44
that how they find them etc etc anyway I
4:46
can't help myself I love that topic so
4:48
definite let me know if you want to hear
4:49
more about it so results for him his Hep
4:51
C antibody is positive is HIV is
4:54
negative his hepatitis B surface
4:55
antibody is positive hepatitis B surface
4:58
antigen is negative his our PR is
5:01
negative and gonorrhea chlamydia with
5:03
again with the star that all his sites
5:04
tested or negative so important
Background
5:07
background before we get into the kind
5:09
of nitty-gritty of this case so Hep C is
5:11
a virus similar to heavy that affects
5:13
liver cells 70% of patients are
5:15
asymptomatic so about 6 weeks after
5:18
exposure they can start to have some
5:20
symptoms where they can have like this
5:21
malaise and fatigue and some patients
5:25
can have have jaundice elevated ast a
5:27
little bit more than alt LT or a ast
5:30
really um conversely to Hep B though
5:34
most patients do not cure it on their
5:36
own only 50% of them max 50% of them
5:39
cured on their own and typically about
5:42
15 to 50 percent so about 50 to 85
5:44
percent of patients go on to develop
5:46
chronic hepatitis C that doesn't go away
5:47
without treatment so of the people who
5:50
have chronic Hep C about 5 to 30%
5:53
develop cirrhosis and that typically
5:55
happens over the course of 20 to 30
5:56
years so scenarios that you just kind of
6:00
some background as well as scenarios for
6:01
testing you could either be screening or
6:03
you could have somebody who's
6:04
symptomatic and basically the testing is
6:05
the same so screening you really want to
6:08
think about patients who use IV drugs or
6:11
intranasal cocaine as well at any point
6:14
even if it was just one time you
6:15
definitely wanna test those patients
6:16
patients who are high-risk continually
6:18
high risk or have risk factors patients
6:20
were born in 1945 to 1965 have a higher
6:23
prevalence so those recommendations just
6:24
make sure you test them at least once
6:26
patients who have HIV were incarcerated
6:29
are currently incarcerated men who have
6:31
sex with men have higher risks and
6:33
patients who are on dialysis as well and
6:35
a certain other ones about organ
6:37
donation or I believe transplantation
6:39
but if they're involved in transplant
6:41
I'm sure somebody's
6:41
screening for them for that anyway but
6:43
fYI and then if you have someone with
6:45
slightly elevated lfts if we go back and
6:47
watch that lecture if you haven't
6:48
watched that already or if you have
6:50
patients who are kind of symptomatic
6:52
that you are worried about or actually I
6:55
didn't include here at post-exposure
6:56
patients who used IV drugs or had sexual
7:01
relations with somebody less commonly a
7:03
sexually transmitted but another thing
7:06
to think about and again going in just a
7:08
second I'm gonna go through the labs and
7:09
I'll talk about kind of like when what
7:11
when to test for which labs but oh yeah
7:14
natural course and that should say Hep C
7:16
not happy HCV RNA so when you're exposed
7:20
to the Hep C virus the RNA levels
7:23
similar to the DNA level and hepatitis B
7:25
is going to be positive in about one to
7:27
two weeks after so if you're thinking
7:28
about somebody who has had an exposure
7:30
to sharing IV drug needles something
7:33
like that you can test the HCV RNA first
7:36
but again it won't become positive for
7:37
one to two weeks the patient can become
7:40
a become symptomatic about six weeks
7:42
after they're exposed if they do again
7:44
thirty percent of them do 70 percent of
7:46
them don't and then patient will clear
7:49
the infection if they do around six
7:51
months after exposure and that is also
7:54
the time where you're going to see that
7:55
hepatitis B antibody positive and then
7:59
once you get that hepatitis C antibody
8:02
it's going to be positive for life and
8:05
it comes that becomes positive about ten
8:07
weeks to about six months and then
8:08
chronic Hep C is when they have
8:10
persistently positive HCV RNA levels and
8:13
that will kind of confirm that they
8:14
currently have an infection so again I
Two labs
8:16
probably have put this one first before
8:17
that slide but the two labs you really
8:19
want to think about our Hep C antibody
8:21
and Hep C RNA way way easier than happy
8:23
in parentheses here I also have the
8:25
genotype in the fibrosis score but hold
8:28
that thought for just a second so
Treatment
8:29
treatment for Hep C um it's basically
8:32
three months worth of antivirals and
8:35
this used to be with like interferon
8:36
like this whole regimen that was really
8:38
hard to tolerate really high
8:39
side-effects basically what happens now
8:41
it's very expensive but it's only three
8:43
months of medications and then they're
8:44
cured basically forever I mean there's
8:46
very low not curing rates for them and
8:49
then there's a couple of them and I have
8:50
them by trade names I apologize because
8:52
the generics are really hard to
8:54
pronounce and these are
8:55
the main ones that you might see kind of
8:57
people talking about our Vani Navarrete
8:59
of clues of wasabi and then there's a
9:01
couple of other ones and again that
9:02
generics are kind of coming out as well
9:05
and typically this is treated by GI
9:07
unless you have a comprehensive program
9:09
in your clinic with like a nurse case
9:11
manager and you're collaborating with
9:12
the GI to ask questions things like that
9:14
and it really depends on the genotype
9:17
that they have how fibrotic they are
9:18
like if they have cirrhosis or not and
9:20
then previous treatment they've had in
9:21
the past if they have any impaired real
9:23
function medications they take and then
9:25
comorbidities so how this really relates
9:27
to you as a PCP is if you kind of walk
9:28
into a situation where you have somebody
9:30
is on their chart that they have
9:31
hepatitis C and the last note from the
9:34
provider was like oh you know continued
9:35
followup with GI and you're kind of just
9:37
dropped into that and that's all the
9:38
information that you have this is kind
9:39
of informing you of like what the deal
9:41
is right so what have they had treatment
9:43
before how do you know and they really
9:46
like if it was discovered like ten years
9:48
ago like hopefully they've had treatment
9:49
we'll talk about I'll talk about why
9:52
they wouldn't get treatment in a second
9:53
but the tests that they need to do first
9:56
before they do treatment is something
9:57
called a fibrous scan and it's a type of
9:59
ultrasound that the GI doctor will do on
10:01
specialist will do rather that is a less
10:04
invasive way than doing a liver biopsy -
10:06
just to determine if they're on our way
10:08
to cirrhosis or if they are cirrhotic
10:10
and then the genotype that they have
10:12
it's I believe there's six of them I
10:13
can't remember now off the top of my
10:15
head but um b1 and creatinine you want
10:17
to make sure that that is in the normal
10:19
range or within an acceptable range to
10:20
treat them so a reason is not to treat
10:23
so this is why it's kind of important to
10:24
you as a PCP because if you have a
10:26
patient with active Hep C that is not
10:27
getting treatment you still need to
10:28
monitor them especially if they're not
10:30
willing to go to GI which happens so
10:34
patients who are at risk for re
10:36
infection so if you have active IV drug
10:38
use and you are either don't feel ready
10:41
because you're not confident in your
10:42
sobriety or you're not quite ready -
10:44
they're just not quite ready with
10:47
sobriety because that's that's a chronic
10:49
illness substance abuse disorder right
10:50
so if they have risks for active for
10:53
reinfection then they may not want to
10:55
treat it right then the patients who
10:57
have cirrhosis the reason why is not
10:59
that that we won't treat them is that
11:00
that patients will who have cirrhosis
11:02
may be heading towards liver transplant
11:04
and it's much easier to get a Hep C
11:06
transplanted have liver who
11:08
has Hep C and then you treat after
11:11
transplant than it is to treat before
11:12
transplant etc etc so monitoring so this
Monitoring
11:16
is why it's kind of important to you as
11:17
a PCP even if you're not treating them
11:19
so you want to read the patients who are
11:21
not getting treatment you want to reduce
11:23
the risk for transmission so that are
11:24
they using clean needles are they
11:25
sharing needles if they have IV drug use
11:28
risk factors for progression um you want
11:30
to make sure that they're minimizing
11:31
those so obesity diabetes you know
11:33
things that can cuts fatty liver
11:35
I'm alcohol use tylenol use some
11:37
medications you want to make sure they
11:39
avoid those things to make sure that
11:40
it's not progressing their their Hep C
11:42
making their cirrhosis worse you want to
11:44
make sure that they have their hepatitis
11:45
B in a vaccination so that's kind of
11:47
like this is part of like your care plan
11:48
when you run into somebody who has epsy
11:50
making sure that they have those
11:52
vaccines and if they don't then you give
11:53
it to them because if they also get
11:55
concurrent happy that could be a lot
11:56
Messier um and a lot more severe of a
11:58
case according to my GI specialist I've
12:00
never seen it but and then substance
12:02
abuse treatment again because this is a
12:03
mental illness it's a chronic illness we
12:04
want to make sure that we're supporting
12:05
them getting them involved with psych if
12:07
they need that and then in terms of the
12:10
monitoring of lfts and fibrosis scoring
12:11
I really would reach out to your GI
12:13
specialist if they're if the patient's
12:14
not willing to go because they can make
12:16
their recommendations going forward
12:17
about like this every six months three
12:19
months etc etc as if I broke the score
12:21
once a year because again if you have a
12:22
younger person with IV drug use versus
12:25
somebody who was born in 1965 who
12:27
happens to have a positive Hep C like
12:29
the person who's had it for a long time
12:30
is more likely to have fibrosis and
12:32
somebody who just acquired it if that
12:34
makes sense and I have this in
12:35
parentheses just as an FYI because I
12:37
have run into this case a number of
12:40
times in the setting that I used to work
12:41
in but if you run into this I definitely
12:44
would be collaborating with your
12:45
supervisor but patients who had chronic
12:47
Hep C and cirrhosis you want to make
12:50
sure that they have all the monitoring
12:52
parameters in place they really should
12:53
be in connected with GI to help you with
12:55
this but if they're not you run into it
12:57
from time to time like I said but still
12:59
manage it with your supervisor but just
13:01
FYI you're gonna be monitoring a q6
13:03
month every six month ultrasound for
13:05
hepatocellular cancer they're going to
13:08
need an endoscopy for esophageal varices
13:09
typically and then they might monitor
13:12
them with something called a meld score
13:13
which is a calculation of a couple of
13:14
labs to kind of give their prognosis of
13:16
how they're doing with their cirrhosis
13:18
so kind of bringing it back to the real
13:20
like basic simple stuff so
13:22
that's just some background information
13:23
if you find yourself in Trenton into
13:25
somebody with Hep C and you're just like
13:27
well what do I do with that and this is
13:28
this is what you do with it is evaluate
13:30
if it's active or not and then you make
13:31
sure that they have seen gi they're
13:33
doing treatment why they're not doing
13:34
treatment etc etc so number one Hep C
13:37
antibody test awesome right if that's
13:40
positive then you want to do the next
13:42
test do you want to do is the HCV RNA to
13:44
verify if it's actually active right
13:46
because Hep C antibody is going to be
13:47
positive for life so if that's if the
13:50
initial Hep C antibody is negative you
13:52
can stop I do want to make a caveat here
13:54
though based on that timeline I should
13:56
have included it here as well but based
13:58
on the timeline of infection depending
14:00
on the scenario we're talking about if
14:02
you have somebody like in this
14:03
particular case who recently used a
14:06
needle from somebody who know they know
14:08
that they have Hep C and they want to
14:09
test today to see if they have Hep C you
14:11
you can't do the eight Hep C antibody
14:13
until it's been about six months so
14:16
hopefully in your history you've
14:17
gathered when their exposure is so you
14:19
don't just do a Hep C antibody for them
14:21
and then it's negative because they
14:23
haven't developed it yet and they have
14:24
active Hep C that kind of thing so again
14:26
you can check that HCV RNA first in one
14:29
to two weeks if you're worried about a
14:30
post exposure testing or if they have
14:33
risk factors for a recent infection you
14:35
could theoretically do that at the same
14:36
time which I guess I could have done for
14:39
this patient but you know it is what it
14:42
is it it's all done so it's something I
14:44
think about going forward so if your HCV
14:47
RNA is detectable do they qualify for
14:50
treatment do they want treatment do they
14:51
have risk factors for the infection do
14:53
they have cirrhosis and then consider
14:55
those pre treatment labs and monitoring
14:57
versus sending them straight to GI
14:59
because that's kind of like your next
15:00
step first as if you did the Hep C
15:02
antibody and it was positive and HCV was
15:04
negative there was no viral load it was
15:06
zero or less than twenty or hover it's
15:08
reported you can just you can stop there
15:10
because it signs of a previous infection
15:12
so yeah so kind of quick recap with him
15:15
so I checked the HCV RNA and
15:17
theoretically I could have checked the
15:19
HCV I could have checked that at the
15:22
initial test depending on when his
15:24
exposures were and his HCV RNA was
15:27
800,000 and so what I want to talk about
15:30
him is that talked to with him about is
15:32
that the natural course is that about
15:33
half ish people will cure it on their
15:35
own with
15:36
in six months and so we don't
15:37
necessarily know when he was infected
15:40
with this right and so typically
15:41
insurance wants you to have that
15:42
document in for about six months before
15:44
they're willing to approve the
15:46
medications because again it's quite
15:47
expensive however don't let that kind of
15:50
deter you but just medically manage them
15:52
and keep that in the back of your mind
15:53
probably he needs to go to GI though
15:55
great because they're gonna help you
15:57
with the testing and the counseling and
15:58
all that kind of stuff
15:59
again fibro sure or fibrous can Piper
16:02
sure is like the blood test that you
16:03
would do if you didn't have access to a
16:04
fibrous can but that's ideal so
16:06
definitely wanna CGI for that do you
16:08
know type and then AB you in and
16:09
creatinine and then kind of just quick
Summary
16:11
recap so John so I'm concerned about a
16:13
chronic Hep C versus an acute Hep C and
16:15
there's really no labs to tell you that
16:17
how a cuter chronic it is sometimes a
16:20
viral load can give you some information
16:21
but for him I did some pretreatment labs
16:24
because he was really freaked out about
16:25
it and he really wanted to get treatment
16:26
and I referred him to GI as well to help
16:28
with that v of scan so I really just did
16:30
the genotype testing and and that's
16:31
pretty much it and then we talked about
16:34
some sexual health counseling some risk
16:36
reduction factors I offered prepped for
16:38
him and if you're not familiar with prep
16:39
I'm happy to make a video about that
16:41
that's a pre exposure prophylaxis for
16:43
HIV for patients who have risk factors
16:46
for you know sexual health risk factors
16:48
or IV drug use declined at the time but
16:51
something I think about
16:52
so substance abuse counseling I brought
16:54
that up as well and if he's interested
16:55
in continuing or stopping heroin and
16:58
smoking cessation as well but typically
16:59
patients are in the middle of a new Hep
17:01
C diagnosis and active IV drug use they
17:03
typically don't want to quit smoking but
17:05
you can mention it and just say um I
17:07
recommend that we don't do that but we
17:08
can tackle that whenever you feel ready
17:10
for that that kind of thing and then for
17:12
him I recommended that he came back for
17:14
a full physical in one to two months
17:15
just to make sure we're talking about
17:16
all the things we want to talk about
17:17
going forward
17:23
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17:25
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there's so many things so definitely hop
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in there if you're interested thank you
18:07
so much again for watching hang in there
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and I'll see you soon
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you

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Liz Rohr