Date:
Patient:
MRN:
Clincian: (Primary Care Physician, Infectious Disease Physician)
Reason for Visit:
Evaluation for suspected or confirmed hepatitis A infection
Review of symptoms and laboratory results
Discussion of management plan and prevention measures
History of Present Illness:
Briefly describe the onset and progression of symptoms:
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) – may develop later
Recent travel to an area with high endemicity of hepatitis A
Consumption of potentially contaminated food or water
Contact with an infected individual
Past Medical History:
Underlying medical conditions (important for potential complications)
Previous vaccinations (including hepatitis A vaccine)
History of other liver diseases
Social History:
Recent travel history (particularly to areas with high endemicity)
High-risk occupations or behaviors (e.g., daycare workers, men who have sex with men)
Physical Exam:
Vital Signs: May be normal or show low-grade fever.
Jaundice (icterus) on skin and sclerae (may be absent early on).
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 A serology:
IgM anti-HAV: Positive result indicates recent or acute infection.
IgG anti-HAV: Positive result indicates past infection or vaccination-induced immunity.
Consider mentioning other labs ordered as needed (complete blood count, coagulation studies).
Imaging:
Imaging studies are not diagnostic for hepatitis A but may be performed to rule out other causes of liver dysfunction (e.g., abdominal ultrasound for fatty liver).
Assessment:
Summarize the diagnosis of acute hepatitis A infection based on clinical presentation, potential exposure history, and positive IgM anti-HAV serology.
Discuss the severity of illness based on symptoms and laboratory findings.
Plan:
Outline the management plan, which is primarily supportive:
Bed rest as needed
Adequate hydration with intravenous fluids if necessary
Anti-nausea medications
Nutritional support with emphasis on easily digestible foods
Advise avoiding alcohol and hepatotoxic medications.
Consider mentioning the need for hospitalization in severe cases with complications (fulminant hepatic failure).
Prevention Measures:
Education on good hygiene practices (handwashing)
Vaccination for unvaccinated individuals or those at ongoing risk (e.g., daycare workers, travelers to high-risk areas)
Post-exposure prophylaxis (vaccination and/or immune globulin) for close contacts within 14 days of exposure.
Prognosis:
Briefly discuss the prognosis. Hepatitis A is usually a self-limited illness with full recovery within 2-6 months.
Discuss potential complications (fulminant hepatic failure) although rare.
Education:
Document any education provided to the patient regarding:
The nature of hepatitis A virus infection and its transmission routes
The importance of good hygiene practices to prevent further spread
Dietary modifications and avoiding alcohol
The benefits and potential side effects of vaccination
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, vaccination, or dietary restrictions.
Address the potential emotional impact of a viral 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 primary care physician or infectious disease specialist for diagnosis, treatment recommendations, and prognosis.