Date:
Patient:
MRN:
Clincian: (Primary Care Physician, Gastroenterologist, Hepatologist)
Reason for Visit:
Evaluation for suspected or confirmed hepatitis B infection
Review of symptoms and laboratory results
Discussion of treatment plan and monitoring strategies
History of Present Illness:
Briefly describe the onset and progression of symptoms (may be absent in chronic infection):
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)
Recent exposure to infected blood or bodily fluids (high-risk behaviors)
History of blood transfusions or organ transplantation (before routine screening)
Birth to an infected mother
Past Medical History:
Underlying medical conditions (important for potential complications)
Previous vaccinations (including hepatitis B vaccine)
History of other liver diseases
Social History:
High-risk behaviors (injection drug use, unprotected sex with multiple partners)
Occupational exposures (healthcare workers, tattoo artists)
Born to an infected mother
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 B serology:
HBsAg: Positive result indicates current infection (carrier or acute).
Anti-HBc: Positive total antibody indicates past or current infection.
Anti-HBs: Positive result indicates immunity from past infection or vaccination.
HBeAg & Anti-HBe: Markers of viral replication (positive HBeAg suggests higher infectivity).
HBV DNA: Quantitative test to assess viral load (important for treatment decisions).
Consider mentioning other labs ordered as needed (complete blood count, coagulation studies).
Imaging:
Imaging studies are not diagnostic for hepatitis B 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 (acute or chronic) based on clinical presentation, potential exposure history, and serology results.
Discuss the stage of infection (acute, chronic carrier, inactive carrier) based on HBsAg and HBeAg status.
Discuss the severity of liver disease based on symptoms and laboratory findings.
Plan:
Outline the treatment plan based on the stage of infection and severity of liver disease:
Acute Hepatitis B:
Primarily supportive care (similar to Hepatitis A).
Antiviral medication may be considered in severe cases.
Chronic Hepatitis B:
Antiviral medication to suppress viral replication and reduce risk of complications (cirrhosis, liver cancer).
Monitoring with regular lab tests and imaging studies.
Vaccination:
Vaccination for unvaccinated individuals or those at ongoing risk is crucial for prevention.
Prognosis:
Briefly discuss the prognosis. Acute hepatitis B usually resolves on its own.
Chronic hepatitis B can be controlled with antiviral medication but may require lifelong treatment.
Discuss the potential complications (cirrhosis, liver cancer) and the importance of monitoring and treatment adherence.
Education:
Document any education provided to the patient regarding:
The nature of hepatitis B virus infection and its transmission routes
The importance of safe sex practices and avoiding high-risk behaviors
Dietary modifications and avoiding alcohol
The benefits and potential side effects of vaccination and antiviral medications
The importance of adherence to treatment and regular follow-up
The need for partner notification and vaccination (if applicable)
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 side effects, or transmission to others.
Address the potential emotional impact of a chronic illness and offer support or referral for mental health services if needed.