Week 6 Case Study: Hepatitis C, Atrial Fibrillation, and COPD Exacerbation

Week 6 case study

Bertha, a 58 – year – old Hispanic female, presents to the primary care clinic to establish care. She states that in 1985 she received a blood transfusion after sustained an MVA. She had tested positive for hepatitis C virus ( HCV ) in the past, but ignored any advice regarding treatment options. She brings a previous lab result with her today that shows :(ALT) level of 85 IU/mL (range 8 – 35 IU/mL). The lab form also states, “ HCV antibody is positive by enzyme immunoassay — confirmation is suggested. The patient also arrived with diagnosis with exacerbation of A-Fib (pulse 110 beats per mint. and COPD exacerbation as well (O2 sat: 87%)

Past medical h story: Hypertension, dyslipidemia, hepatitis C.

Family history: Unremarkable

Social history: She works as a case manager of an HMO and is married with 2 children. Denies use of illegal drugs, denies alcohol abuse, and has no tattoos.

Medications: HCTZ, 12,5 mg daily; Atorvastatin 20 mg daily, Metoprolol Succinate 25 mg and Pro-Air HFA 90mcg one puff q 4- 6 hrs as needed x pain.

Allergies: No known drug or food allergies.

OBJECTIVE General a ppearance: 58 – year – old female; pleasant, in no acute distress; good eye contact. Vital signs: T: 96.8; P: 110; RR: 23; SaO 2 : 87; BP: 150/100. Her weight is 214 lb, and her height is 6.3 inches.

HEENT : Negative. Neck: Thyroid nonpalpable. No lymphadenopathy.

Cardiovascular: A-fib rhythm. irregular and rapid heartbeat.

Respiratory: Crackles and Wheezing.

Abdomen: Mild tenderness in right upper quadrant. BS x 4 no bruits. Nondistended, soft. No organomegaly. No ascites.

Neurological: A & O × 4, CN II – XII grossly intact.

Depression scale: negative. Musculoskeletal: Full ROM. No deformities. Muscle strength is 5/5.

CRITICAL THINKING

Which diagnostic or imaging studies should be considered confirm the

diagnosis?

What is the most likely differential diagnosis?

What is your plan of treatment?

Are there any emergency referrals needed?

What is first line treatment for AFib in patients with the mentioned comorbidities?

What is the first line of treatment for COPD exacerbation?

📖 Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!

This case study asks you to apply clinical reasoning by analyzing a patient presentation, identifying the most likely diagnoses, and creating a treatment plan. Here’s a structured way to approach it:

Step 1: Read and Break Down the Case

• Patient: 58-year-old Hispanic female.

• Key conditions: history of HCV infection, A-fib exacerbation, and COPD exacerbation.

• Objective findings:

  • ALT elevated (85 IU/mL) → indicates liver injury.

  • SaO₂ 87%, RR 23, crackles & wheezing → COPD exacerbation.

  • A-fib with rapid ventricular response (HR 110).

  • BP 150/100 → uncontrolled hypertension.

Step 2: Diagnostic and Imaging Studies

• HCV Confirmation:

  • HCV RNA PCR test (to confirm active infection).

  • Liver ultrasound or FibroScan to assess fibrosis/cirrhosis.

  • Comprehensive metabolic panel (LFTs, bilirubin, albumin).

• A-fib:

  • ECG (to confirm rhythm and rate).

  • Echocardiogram (to check structural heart disease).

• COPD Exacerbation:

  • Chest X-ray (to rule out pneumonia/CHF).

  • Arterial blood gases (ABG) if hypoxia persists.

Step 3: Differential Diagnosis

1. Chronic Hepatitis C with active infection (based on transfusion history, positive antibody, elevated ALT, RUQ tenderness).

2. Atrial fibrillation with rapid ventricular response (irregular, HR 110).

3. COPD exacerbation with hypoxemia (O₂ sat 87%, wheezing, crackles).

4. Other considerations: congestive heart failure (due to A-fib + crackles), medication-induced liver injury (statin).

Step 4: Treatment Plan

• Hepatitis C:

  • Refer to hepatology for evaluation and initiation of direct-acting antiviral (DAA) therapy.

  • Monitor LFTs and viral load.

• Atrial Fibrillation:

  • Rate control: Beta-blocker (Metoprolol) or Calcium channel blocker (Diltiazem) (already on Metoprolol, dose adjustment may be needed).

  • Anticoagulation assessment (CHA₂DS₂-VASc score).

• COPD Exacerbation:

  • Supplemental oxygen to maintain SaO₂ > 90%.

  • Short-acting bronchodilator (albuterol inhaler or nebulizer).

  • Systemic corticosteroid (Prednisone 40 mg x 5 days).

  • Consider antibiotics if bacterial infection suspected.

• Hypertension:

  • Monitor closely, adjust antihypertensive regimen.

• Lifestyle:

  • Smoking cessation counseling if applicable, weight management, vaccinations (flu, pneumococcal, hepatitis A/B if non-immune).

Step 5: Emergency Referrals

• Immediate referral to cardiology if unstable A-fib with hemodynamic compromise (hypotension, chest pain, syncope).

• Pulmonology if hypoxemia does not improve with oxygen and bronchodilators.

• Hepatology for chronic hepatitis C management.

Step 6: First-Line Treatments

• Atrial Fibrillation with comorbidities (HTN, COPD, HCV):

  • Beta-blocker (Metoprolol) for rate control (caution in COPD, but cardio-selective β-blockers are preferred).

  • Anticoagulation if CHA₂DS₂-VASc ≥ 2.

• COPD Exacerbation:

  • Oxygen + short-acting bronchodilator (Albuterol ± Ipratropium).

  • Oral corticosteroids (Prednisone).

  • Antibiotics if increased sputum or purulence.