Date:
Patient:
MRN:
Clincian: (Primary Care Physician, Gastroenterologist, Hepatologist)
Reason for Visit:
Evaluation for suspected or confirmed hepatitis C 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 (often 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)
Injection drug use
Past Medical History:
Underlying medical conditions (important for potential complications and treatment decisions)
Previous treatments for hepatitis C
History of other liver diseases
Social History:
High-risk behaviors (injection drug use, tattooing with non-sterile equipment)
Occupational exposures (healthcare workers with needlestick injuries)
History of blood transfusions or organ transplantation (before routine screening)
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 C antibody (anti-HCV):
Positive result indicates current or past infection.
HCV RNA: Quantitative test to detect viral presence and assess viral load (important for treatment decisions).
HCV Genotype: Identifies the specific strain of HCV which helps guide treatment choices.
Consider mentioning other labs ordered as needed (complete blood count, coagulation studies).
Imaging:
Imaging studies are not diagnostic for hepatitis C 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 or for patients with advanced fibrosis.
Assessment:
Summarize the diagnosis (acute or chronic) based on clinical presentation, potential exposure history, and anti-HCV and HCV RNA results.
Discuss the stage of infection (acute or chronic) based on anti-HCV results.
Discuss the severity of liver disease based on symptoms, laboratory findings, and imaging studies (if performed).
Mention the HCV genotype identified.
Plan:
Outline the treatment plan based on the stage of infection, severity of liver disease, and HCV genotype:
Antiviral Treatment: Direct-acting antivirals (DAAs) are the mainstay of treatment, with high cure rates (>95%). Treatment duration and specific medication combinations vary based on genotype and other factors.
Monitoring: Regular lab tests and possibly imaging studies to assess response to treatment and monitor for complications.
Vaccination: Vaccination for hepatitis A and B is recommended to prevent co-infection.
Prognosis:
Briefly discuss the prognosis. Hepatitis C can be cured with antiviral treatment. Early diagnosis and treatment are crucial to prevent complications (cirrhosis, liver cancer).
Discuss the importance of treatment adherence and monitoring for cure.
Education:
Document any education provided to the patient regarding:
The nature of hepatitis C virus infection and its transmission routes
The importance of safe practices to prevent transmission
Dietary modifications and avoiding alcohol
The benefits and potential side effects of antiviral medications
The importance of adherence to treatment and regular follow-up
The need for partner notification (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 treatment 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.
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, gastroenterologist,