Hepatitis C Case Study: Lab Interpretation for New Grad NPs
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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
We made a cheat sheet to go along with this episode! Download your cheat sheet here.
Lab Interpretation Crash Course
If you liked this episode, it's a sneak preview of how we cover labs inside our comprehensive Lab Interpretation Crash Course. It covers CBC, CMP, Urinalysis, Dipstick & Microscopy, TSH, Lipids & top Endocrine labs in primary care, and comes with lifetime access and continuing education credits! Check it out here.
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0:00
if you find yourself confused by
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hepatitis C both the labs to order how
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to interpret them and then your role as
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a PCP this video is all about that if
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you're new here I'm Liz Rohr from real
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world and P and you're watching and free
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practice means simple the weekly videos
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to help save you time frustration and
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help you learn faster so you can take
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the best care of your patients so also
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included in this video is going to be a
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cheat sheet so definitely download it
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below this video
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print it out keep it at your desk for
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quick reference got some great extra
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resources too if you want to learn more
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also if you're if you're on a lab
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interpretation journey if you'd like to
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join us for the lab interpretation crash
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course for new nurse practitioners it
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opens next week and I'm so excited so if
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you're interested to get on the wait
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list to get emails about that it's
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real-world 2np comm slash labs and then
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I'll give you all the details there
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without further ado though I'm gonna
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share my screen with you so this is the
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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
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clinic it's not his real name or his
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phone out so he's assumption care with a
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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
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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
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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
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so no no family history a past surgical
2:40
history past medical history he doesn't
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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
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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
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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
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you can be mindful of but don't stress
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out too much about especially if you're
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brand new or if you're still a student
3:19
because that's kind of how we all
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progress and how we all learn but I'm
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trying to be more mindful of it and
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really make really make solid decisions
3:27
about when to test labs for people and
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when not to and I still feel conflicted
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about it I don't feel great but there's
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no real guidelines about ordering like a
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a CMP or a CBC for this patient so
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really I focused on his risk factors and
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so I only tested for him Hep C antibody
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is HIV because he has risk factors of IV
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drug use which I'm going to talk about
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in a second Hep B service antigen and
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antibody if you haven't watched the Hep
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B lecture definitely go back and do that
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that was last week what kind of help you
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feel comfortable with those labs but
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just looking for that because I wasn't
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able to get like a clear history in
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terms of a sexual history about condom
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use and how many partners and and who
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his partners are and things like that
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um syphilis testing are PR because it's
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one of those sexually transmitted
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infections it's a more it's on the rise
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there are certain populations where it's
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on the rise more so than others but I
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believe that IV drug use kind of also
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predisposes you to that and then
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gonorrhea and chlamydia I have a star
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here because really I actually could do
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a whole video about sexual health
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history and testing and I'd love to go
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into that but I'm
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little worried about getting censured by
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YouTube so I'm not gonna get into it
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super a lot right now
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but you really want to make sure you're
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you're testing all the sites of exposure
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not just a urine sample and so really
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getting a good history about that with
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your patience and kind of who their
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sexual partners are and and things like
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that how they find them etc etc anyway I
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can't help myself I love that topic so
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definite let me know if you want to hear
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more about it so results for him his Hep
4:51
C antibody is positive is HIV is
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negative his hepatitis B surface
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antibody is positive hepatitis B surface
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antigen is negative his our PR is
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negative and gonorrhea chlamydia with
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again with the star that all his sites
5:04
tested or negative so important
Background
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background before we get into the kind
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of nitty-gritty of this case so Hep C is
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a virus similar to heavy that affects
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liver cells 70% of patients are
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asymptomatic so about 6 weeks after
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exposure they can start to have some
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symptoms where they can have like this
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malaise and fatigue and some patients
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can have have jaundice elevated ast a
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little bit more than alt LT or a ast
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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
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percent of patients go on to develop
5:46
chronic hepatitis C that doesn't go away
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without treatment so of the people who
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have chronic Hep C about 5 to 30%
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develop cirrhosis and that typically
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happens over the course of 20 to 30
5:56
years so scenarios that you just kind of
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some background as well as scenarios for
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testing you could either be screening or
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you could have somebody who's
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symptomatic and basically the testing is
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the same so screening you really want to
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think about patients who use IV drugs or
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intranasal cocaine as well at any point
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even if it was just one time you
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definitely wanna test those patients
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patients who are high-risk continually
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high risk or have risk factors patients
6:20
were born in 1945 to 1965 have a higher
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prevalence so those recommendations just
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make sure you test them at least once
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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
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donation or I believe transplantation
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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
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watch that lecture if you haven't
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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
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relations with somebody less commonly a
7:03
sexually transmitted but another thing
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to think about and again going in just a
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second I'm gonna go through the labs and
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I'll talk about kind of like when what
7:11
when to test for which labs but oh yeah
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natural course and that should say Hep C
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not happy HCV RNA so when you're exposed
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to the Hep C virus the RNA levels
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similar to the DNA level and hepatitis B
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is going to be positive in about one to
7:27
two weeks after so if you're thinking
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about somebody who has had an exposure
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to sharing IV drug needles something
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like that you can test the HCV RNA first
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but again it won't become positive for
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one to two weeks the patient can become
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a become symptomatic about six weeks
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after they're exposed if they do again
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thirty percent of them do 70 percent of
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them don't and then patient will clear
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the infection if they do around six
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months after exposure and that is also
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the time where you're going to see that
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hepatitis B antibody positive and then
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once you get that hepatitis C antibody
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it's going to be positive for life and
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it comes that becomes positive about ten
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weeks to about six months and then
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chronic Hep C is when they have
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persistently positive HCV RNA levels and
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that will kind of confirm that they
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currently have an infection so again I
Two labs
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probably have put this one first before
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that slide but the two labs you really
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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
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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
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very low not curing rates for them and
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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
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pronounce and these are
8:55
the main ones that you might see kind of
8:57
people talking about our Vani Navarrete
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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
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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
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and it really depends on the genotype
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that they have how fibrotic they are
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like if they have cirrhosis or not and
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then previous treatment they've had in
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the past if they have any impaired real
9:23
function medications they take and then
9:25
comorbidities so how this really relates
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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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you
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