Question

You obtain the following information from EPIC regarding your patient Mrs. Rodriguez. Mrs. Rodriguez was admitted to the hospital 2 days ago with a diagnosis of Hepatitis C. She is 43 years old, 5’3”, and weighs 140 lbs. She has a history of intravenous drug use but has not engaged in this behavior for over 10 years. Mrs. Rodriguez also has a history of angina. She came to the hospital complaining of chest pain, and nausea. She is currently NPO and has an IV with normal saline running at 125 mL/hr. Vital signs from night shift were 98.8°F, 92, 16, 158/72.

Medications: Ribavirin 600mg PO BID

Interferon alpha-2b – 3 million IU subcutaneously three times a week

Lisinopril 10 mg PO every day

Hydrochlorothiazide 25 mg PO every morning

Clopidogrel 75 mg PO every day

Nitroglycerin 0.3 mg sl every 5 minutes prn up to 3 doses in 15 minutes for chest pain

Acetaminophen 500 mg (1 or 2 tabs) PO every 4 hours prn for pain

Labs:

Alanine aminotransferase (ALT) – 210 Units/L

Aspartate aminotransferase (AST) – 162 Units/L

Total bilirubin 3.5 mg/dL (0.1 – 1.0 mg/dL)

HCV RNA positive

BNP (b-Type natriuretic peptide) 425 mcg/L (<100 mcg/L)

Cholesterol 310 mg/dL (<200 mg/dL)

Troponin 1 < 0.1 mg/mL (<0.1 mg/mL)

Questions: Mrs. Rodriguez

1. What is your priority concern for this patient? Why?

2. What would you do to help this patient?

3. Based on the patient history, how do you think this patient contracted hepatitis C?

4. Does this patient have an active case of hepatitis C? How do you know?

5. What is the significance of the BNP? The Troponin level?

6. What labs would be important to monitor for this patient based on the signs, symptoms, and medications the patient is taking?

7. Do you have concerns about the acetaminophen dosing for Mr. Rodriguez? Why?

Answer 1

Hepatitis: Inflammation of Liver cells is called Hepatitis.  

Hepatitis C : An acute form of Hepatitis transmitted by blood, sexual contact and body fluids.  

1. Priority concern for Mrs. Rodriguez is her impairment in cardiac function.  

Her laboratory values show that :

*Elevated B Natriuretic peptide: B Natriuretic peptide is a hormone , that produced by the heart, when there is considerable pressure changes inside the heart.  When heart is unable pump adequately , the more BNP is produced from it. So elevated BNP level indicates the the risk of heart failure.  

* The elevated troponin level: indicates the impairment of cardiac function. Troponin is a protein, that is essential for cardiac muscles to contract and is produced by cardiac muscles . Al elevated level of troponin is an indicator of heart damage.

2. To help the patient:

* Provide a comfortable position, cardiac position with the help of a cardiac table can be helpful for the patient. It eases the respiration due to lung expansion.  

*Provide Psychological support to the patient to relieve stress, as stress can increase the troponin level.

* Monitor vital signs every 4 hrly.

*Assess signs of any cardiac complications

* Administer medications as per physician's order.

* Provide a heart healthy diet with low fat and low carbohydrates.  

3. Hepatitis C:

Based on patient history, it is clear that she got contracted with the Hepatitis C , due to her intravenous drug abuse in her past life. Hepatitis C is a viral infection, that transmit through body fluids and , blood. Drug abusers, usually use contaminated syringes, that used by different other drug abusers.  

4. Active case of Hepatitis C:

Laboratory test is positive for HCV RNA , that indicates the patient is an active case of Hepatitis C. Also patient Bilirubin level, AST and ALT ( liver enzymes) are high that indicates the liver damage.  

5. ( mentioned in 1 answer)

6. Based on Signs and symptoms, the following lab values has to be checked:

* ELectro cardiogram , has to be checked to detect any abnormalities in heart rhythm.

* Serum elelectrolyte levels for Sodium, potassium etc. : patient is on Diuretics , Hydrochlorothiazide, risk of electrolyte imbalance, that can lead to abnormalities in BP and heart beat.

7. Acetaminophen :

A white crystalline compound used in medicine as an anodyne to releive pain and to reduce fever. Acetaminophen , recommended maximum dosage for adult is 4gm per day.

If patient takes 2 tabs every 4 hr ( 500 mg ) ,it can exceed the maximum limit . Also Acetaminophen can cause liver or renal damage . So it is dangerous for the patient to take Acetaminophen in this increased dose. Physician has to reduce the dose of Acetaminophen.