Case Study Overview of learning achieved through postgraduate course: advanced assessment and clinical reasoning Becky KaKei Leong, Bachelor of Nursing, Community Hepatitis Nurse from The Hepatitis Foundation of New Zealand
12C Princess Street, Takanini, Auckland 2112 p: 021 103 7805 e: beckakei@gmail.com Conflict of interest and / or financial disclosure: no conflict of interest or any financial related matter
Introduction
is active and is rapidly replicating, hepatitis B e-antigen (HBeAg) protein is secreted into the bloodstream (Liu et al, 2016). Her HBeAg is positive and she has been in immune-tolerant phase for at least ten years.
Hepatitis B is a silent disease; it often does not present any significant disturbances or disabilities until the condition is advanced; often asymptomatic or mild symptoms.
Physical exam and diagnostics
There is no medical intervention to cure chronic hepatitis B (CHB) (Tu et al, 2018); it increases the risks of developing liver cirrhosis, hepatic failure, and hepatocellular carcinoma (HCC). People living with CHB are recommended to engage in lifelong liver surveillance (bpac, 2018) to monitor disease progression and provide timely treatment to reduce the risk of HCC and the development of cirrhosis (Terrault et al, 2018).
On examination, her vital signs are within normal parameters, minimal voluntary guarding. Normal JACCOL assessment. Reassuring physical examination, negative Murphy’s sign. Yan’s presenting complaints are typical signs of cholelithiasis with biliary colic pain (Tanaja et al, 2020). Yan meets the risk profile of high-risk groups being a female, age between 30 to 75 (bpac, 2014), use of oral contraceptives, her recent dietary alteration (overall reduction of intake and dietary cholesterol), along with chronic liver disease with HBeAg positive could be contributing factors to developing gallstone disease (Li et al, 2016).
The role of community hepatitis nurse is expanding to meet the high demand from higher level of screening for positive CHB and the aging population increasing in the risk of developing hepatitis B related liver complications. Engaging with patients and developing a strong rapport is essential in a service that provides lifelong monitoring, patients are empowered to contact community nurses for advice when experiencing gastro symptoms that maybe related to hepatitis flare.
Her high viremia CHB in the past ten years with her alanine transaminase (ALT) gradually elevated; in the context of her previous blood test pattern in relations to her presenting symptoms, it is a possible indication of hepatitis flare related to HBeAg seroconversion or transitioning from immunetolerance CHB to becoming immune active CHB. Viral flare can be asymptomatic; however, fatigue, loss of appetite, weight loss, nausea and vomiting can be present (Li et al, 2016).
In the postgraduate course advanced assessment and clinical reasoning; I have learnt to utilize various structural frameworks to begin differential diagnostic assessment to explore the cause of presenting complaints. Yan is a pseudonym; she has consented to use her event for the case study with omission or alteration to any specific information that may identify her.
In the context of this case, HBV DNA Quantitation combining liver function test provides a high prediction of viral flare with a “sensitivity and a specificity both of 86%” (Chang & Liaw, 2014).
Case study Health history collection using the OLDCART framework:
CHB is a dynamic disease; as the presentation of the complications of CHB is vastly different from one person to another, additionally the transition between inactive to active phases of the disease can be unpredictable (Terrault et al, 2018).
Yan is a 40-year-old Chinese female, afebrile, she was having moderate intermittent right upper quadrant (RUQ) abdominal pain over the past two months. Pain has worsened over time, aggravates after eating, and resolves spontaneously within 2 hours at its longest duration. Two weeks ago, she began having nausea and vomiting with epigastric pain. She feels fatigued, and her weight is down from 68kg to 65kg. She has also noticed her urine colour darkened but no obvious haematuria and dysuria.
According to the international guidelines for CHB infection, normal ALT for healthy females is ranged between 19-25U/L. This value is lower than the normal enzyme reference range in New Zealand local laboratory for ALT of normal range <40 U/L. The fundamental determinant of the threshold for treatment is based on changes in ALT, with values more or equal to two times upper limit of normal (ULN) (Terrault et al, 2018).
Yan has presented with classic symptoms of gallstone disease; she also is living with CHB infection, which a hepatitis flare could also have similar presentations. When the hepatitis B virus (HBV) 8
