Date:
Patient:
MRN:
Clincian: (Hepatologist, Gastroenterologist)
Reason for Visit:
Evaluation for suspected or confirmed hepatitis D infection
Review of symptoms and laboratory results
Discussion of management plan
History of Present Illness:
Briefly describe the onset and progression of symptoms (may be similar to hepatitis B):
Fatigue
Loss of appetite
Nausea, vomiting
Abdominal pain (usually right upper quadrant)
Dark urine (due to bilirubin buildup)
Jaundice (yellowing of the skin and eyes)
Known diagnosis of chronic hepatitis B infection (essential for HDV)
Recent high-risk exposure to hepatitis B (suggests co-infection)
Past Medical History:
Underlying medical conditions (important for potential complications)
Diagnosis of chronic hepatitis B
Previous treatments for hepatitis B
History of other liver diseases
Social History:
Similar risk factors as hepatitis B (injection drug use, unprotected sex)
History of blood transfusions or organ transplantation (before routine screening) in some regions
Physical Exam:
Vital Signs: May be normal or show low-grade fever.
Jaundice (icterus) on skin and sclerae.
Hepatomegaly (enlarged liver) on palpation (may be tender).
Consider mentioning splenomegaly (enlarged spleen) if present.
Labs:
Liver function tests (LFTs):
Elevated bilirubin (conjugated and unconjugated) and liver enzymes (ALT, AST) are suggestive of liver inflammation.
Hepatitis B serology:
Positive HBsAg confirms presence of hepatitis B (essential for HDV).
Hepatitis D antibody (anti-HDV):
Positive result indicates current or past HDV infection.
Consider mentioning other labs ordered as needed (complete blood count, coagulation studies).
Imaging:
Imaging studies are not diagnostic for hepatitis D but may be performed to rule out other causes of liver dysfunction (e.g., abdominal ultrasound for fatty liver).
Liver biopsy may be considered in some cases for further evaluation of liver damage.
Assessment:
Summarize the diagnosis of hepatitis D co-infection with chronic hepatitis B based on clinical presentation, known HBV infection, and positive anti-HDV antibody.
Discuss the severity of liver disease based on symptoms, laboratory findings, and imaging studies (if performed).
Plan:
Outline the management plan, noting limited treatment options for HDV itself:
Treatment of underlying hepatitis B: Antiviral medications to suppress HBV replication can indirectly improve HDV outcomes.
Supportive care: Similar to management of hepatitis B (rest, hydration, nutritional support).
Evaluation for liver transplantation: In severe cases with complications (decompensated cirrhosis).
Vaccination for hepatitis B is crucial for preventing new HDV infections in susceptible individuals.
Prognosis:
Briefly discuss the prognosis. HDV is the most severe form of chronic viral hepatitis due to its rapid progression to liver damage. Prognosis depends on the severity of liver disease at diagnosis and adherence to treatment for hepatitis B.
Discuss the potential complications (cirrhosis, liver cancer) and the importance of monitoring and management.
Education:
Document any education provided to the patient regarding:
The nature of hepatitis D virus infection and its dependence on hepatitis B
The importance of adhering to treatment for hepatitis B to manage HDV
Dietary modifications and avoiding alcohol
The importance of avoiding behaviors that can worsen liver disease
Warning signs and symptoms of worsening illness (severe abdominal pain, confusion)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and management plan, and any concerns they may have about complications, treatment limitations, or disease transmission.
Address the potential emotional impact of a severe chronic illness and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hepatologist or gastroenterologist for diagnosis, treatment recommendations, and prognosis.