Case Study: Task:1 ( 2 pages and 3 references)
1)A forty-nine-year-old healthy Caucasian female has her routine labs done, which reveals the following:
• ALT 381 ↑↑
• AST 184 ↑↑
• ALP 64
• GGT 14
• Alb, INR, plt normal
She has had liver tests in the past and her ALT and AST fluctuate from normal to 300 s.
• Autoimmune markers negative. She is on no meds.
o What is your next best action to take and why? Further history?
o Diagnostics? What are some of your differentials?
2) Mrs. Keppy is a fifty-five-year-old married female who comes to your office because her husband was recently diagnosed with hepatitis C. She wants to know if she should be tested and what she can expect from her husband’s diagnosis. What will you say to her regarding her risk factors and her husband’s treatment and prognosis?
Task:2 (2 pages and 2 references)
A patient comes in to see you with new complaints of feeling weak and tired. She also admits to some new palpitations. You get an EKG to assess her heart rhythm and note very tall-peaked T waves.
• In reviewing the endocrine disorders, what are some of your differential diagnosis?
• What would be the most important information to obtain in her history and review of systems?
• What diagnostic tests would you order next?
Tasks: 3 (2 pages and 3 references)
What guidelines are available for the diagnosis and management of anemia? Choose one type of anemia and list 3 sets of guidelines you were able to find. Which of these did you find most helpful for clinical use and why? Which did you find least helpful?
Is anemia a normal finding in the geriatric population? What evidence did you find to back up your answer?
SOLUTION TO THE CASE STUDY
Task 1: Several follow-ups are required for patients with elevated ALT and AST levels, especially if they are asymptomatic. In this case, there is a severe elevation of ALT and AST levels as they are more than three times the normal ranges. I would perform further investigations through history, physical examination, serology and liver function tests to establish the underlying cause of chronic alcohol abuse, hepatitis B or C infection, or undetected liver cirrhosis. I would gather the patient risk factors for viral hepatitis and alcohol abuse through history. Serology tests are vital in establishing whether hepatitis B or C infections as the cause of elevated ALT and AST levels. Serology detects hepatitis B surface antigen and antibody in hepatitis C; however, the hepatitis C antibody test is followed by a polymerase chain reaction test if positive. According to Mohamed-Ali et al. (2020), results of persistently elevated liver enzymes in patients in the asymptomatic stage of hepatitis B are associated with high infectivity rates. I would perform a liver aetiology screen to help diagnose liver cirrhosis, non-alcoholic steatohepatitis (NASH), and any hepatobiliary conditions through ultrasound. Depending on the ultrasound results, the patient might need a referral to a hepatologist for further assessment and treatment. The liver aetiology screen also helps establish the presence of anti-mitochondrial, anti-smooth muscle, and antinuclear antibodies associated with elevated AST and ALT levels. Other parameters associated with these raised values include serum immunoglobulins, ferritin, and transferrin saturation. I would also perform a creatinine-kinase measurement to determine whether the increased AST and ALT levels are from a muscular origin, i.e., muscle dystrophy.
Muscle dystrophy is a probable diagnosis as it manifests with increased ALT and AST levels. Other differentials include viral hepatitis and alcohol-induced hepatocellular injury. According to Lala, Goyal, and Mintal (2021), the AST/ALT ratios are critical in diagnosing the underlying conditions. Following the general guidelines, an AST/ALT ratio of less than indicates non-alcoholic fatty liver disease. A ratio equal to one indicates viral hepatitis or drug-related hepatotoxicity. A ratio higher than one indicates cirrhosis. A ratio higher than two indicates alcoholic liver disease. The ratio in this case study is 1:2, implying that ALT is higher than AST, which is consistent with the guideline diagnosis of non-alcoholic fatty liver disease. Therefore, the most probable diagnosis, in this case, is non-alcoholic fatty liver disease.
Hepatitis C risk factors and treatment options
Hepatitis C is a viral infection transmitted via body fluids. I would advise the couple on that the risk factors for contracting the infection include: the use of medical equipment that are not thoroughly sterilized, transfusion of unscreened blood and blood products, using injected drugs by sharing the same needle with infected people, having multiple sexual partners, and men who have sex with men (WHO, 2021).
Regarding treatment, an acute hepatitis C infection might not always need medication since an immune response will clear it. However, treatment is required if the immune system is compromised and the infection progresses. According to WHO (2021), pan-genotypic direct-acting antivirals have excellent efficacy in treating hepatitis C in adults, given in a duration of 12 to 24 weeks depending on the degree of cirrhosis or its absence. Regarding the prognosis, an acute hepatitis C illness is short term. Chronic infections can be treated successfully in six months. However, if left untreated, the associated complications are liver cirrhosis, hepatocarcinoma, and death.
Tall peaked T waves are an indication of hyperkalemia. Several endocrine disorders present with hyperkalemia. Based on this deduction, the differential diagnosis is acute kidney injury, metabolic acidosis as in diabetic ketoacidosis, use of medications that impair renal potassium excretion, dehydration, and excessive potassium intake.
History and review of systems
Most individuals with elevated potassium levels are asymptomatic. When symptomatic, the manifestations are non-specific and significantly related to cardiac and muscular function (Simon, Hashmi & Pharell, 2021). From history, I would obtain the patient’s complaints of fatigue, lethargy, shortness of breath, palpitations. For further investigation of the underlying issues, I would question the patient’s eating habits. Unusual diets containing potassium-rich foods and little or no sodium can potentially lead to hyperkalemia. These foods include bananas, nuts, oranges, melons, raisins etc. I would also enquire about any terminal illnesses like cardiac disease, diabetes mellitus, and hypertension. These conditions are associated with diets involving low sodium and high potassium intake. I would also enquire whether they use potassium supplements, including pharmacologic agents, dietary supplements or salt substitutes.
On review of systems, most findings are normal. However, on musculoskeletal system, I would enquire from the patient and assess for muscle weakness. On circulation system, a cardiovascular examination might reveal palpitations, bradycardia, and extrasystoles due to cardiac block or tachypnea due to respiratory muscle weakness (Simon, Hashmi & Pharell, 2021). Additionally, peripheral pulses might be weak, slow or irregular. Abnormal ECG readings back up all these findings. A review of the gastrointestinal system will reveal nausea and ileus.
I would order blood work of serum potassium. A serum electrolyte of more than 5.5mEq/L indicates hyperkalemia, even in patients at risk of it. I would also perform an ECG. Hyperkalemia is marked by slow conduction, widened PR interval, shortened QT interval, and tall peaked T waves (Simon, Hashmi & Pharell, 2021). Beyond 6.5 mEq/L, the conduction is slower, the QRS interval is wider, and there is no P wave. Eventually, the QRS complex disappears, and a sine wave pattern forms (Simon, Hashmi & Pharell, 2021). At this point, ventricular fibrillation or asystole follows. I would also order urine potassium, sodium, and osmolality tests. I would order for compete blood count and metabolic profile to establish any underlying condition.
Several guidelines are available for diagnosing, treating, and managing different types of anaemia. Among them are World Health Organization guidelines, Centers for Disease Prevention and Control, the British Society of Gastroenterology guidelines, and British Columbia guidelines.
I found guidelines from the American Society of Hematology, the British Society of Gastroenterology, and British Columbia for iron deficiency anaemia. In my opinion, the British Society of Gastroenterology guidelines is the most helpful in diagnosing and managing anaemia in a clinical setting. According to Snook et al. (2021), guidelines suggest that measurement of serum ferritin is key before establishing a diagnosis of iron deficiency anaemia. This is because it is the principal marker of the condition. Other tests can be performed if ferritin is suspected to be a false normal. Other initial diagnostic tests are urinalysis, urine microscopy, upper and lower gastrointestinal endoscopy, and screening for celiac disease. The guideline recommends using gastroscopy and colonoscopy as first-line investigations in men and postmenopausal women. A computer tomography (CT) colonography is an effective alternative for patients who cannot undergo colonoscopy.
For treatment, Snook et al. (2021) recommend initial treatment with one ferrous sulfate, fumarate or gluconate tablet per day. Dosages are tapered to one tablet every 48 hours for those who cannot tolerate the medication. Alternatively, oral formulations and parenteral iron are available. Parenteral iron is recommended in cases where oral iron is ineffective, contraindicated or not well tolerated. Occasional transfusion of packed red cells might be required in addition to iron replacement therapy. The guideline recommends patient Hemoglobin level monitoring in the first one month, and if the outcome is good, treatment should proceed for at least 3 months. Finally, regular monitoring of blood count should be done every six months after the Hemoglobin levels are restored to normal.
Anaemia in the geriatric population
Anaemia affects a significant portion of the geriatric population, making it a common finding. The elderly are people above the age of 65 years. According to Afaghi et al. (2021), the concentration levels of haemoglobin decreases with age. The normal haemoglobin levels according to the WHO is at least 12g per deciliter in women and at least 13g per deciliter in men. The study points out the high prevalence rates of anaemia, approximately 17% in a cohort study and 10 to 24% in a prospective registry study, reported among the geriatric in Europe and the U.S. (Afaghi et al., 2021). Halawi et al. (2017) attribute the decline in haemoglobin to nutritional deficiencies, age-related inflammatory processes, chronic illnesses such as kidney disease, and unexplained loss. A study by Melku et al. (2018) also agrees that it is a public health concern, which is often underdiagnosed, and patients are mostly not informed due to the assumption that it’s the result of ageing or a disease marker. However, the complications associated with anaemia in the geriatric are severe and have adverse effects on the quality of life. they include exacerbation of the chronic illnesses, impaired cognitive and physical abilities as well as impaired nutrient absorption leading to increased frailty. Therefore, timely diagnosis and initiation of treatment are paramount to improving the geriatric quality of life.
Afaghi, H., Sharifi, F., Moodi, M., AnaniSarab, G., Kazemi, T., Miri-Moghaddam, E., & Tahergorabi, Z. (2021). Prevalence of anemia and associated factors among the elderly population in South Khorasan, Birjand, 2019. Medical Journal of the Islamic Republic of Iran, 35, 86.
Halawi, R., Moukhadder, H., & Taher, A. (2017). Anemia in the elderly: a consequence of aging?. Expert review of hematology, 10(4), 327-335.
Lala, V., Goyal, A., & Minter, D. A. (2021). Liver function tests. In StatPearls [Internet]. StatPearls Publishing.
Melku, M., Asefa, W., Mohamednur, A., Getachew, T., Bazezew, B., Workineh, M., … & Terefe, B. (2018). Magnitude of Anemia in Geriatric Population Visiting Outpatient Department at the University of Gondar Referral Hospital, Northwest Ethiopia: Implication for Community-Based Screening. Current gerontology and geriatrics research, 2018.
Mohammed-Ali, Z., Brinc, D., Kulasingam, V., & Selvaratnam, R. (2020). Defining appropriate utilization of AST testing. Clin Biochem, 79, 75-7.
Simon, L. V., Hashmi, M. F., & Farrell, M. W. (2021). Hyperkalemia. StatPearls [Internet].
Snook, J., Bhala, N., Beales, I. L., Cannings, D., Kightley, C., Logan, R. P., … & Goddard, A. F. (2021). British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut, 70(11), 2030-2051.
World Health Organization (WHO). (2021). Hepatitis C. retrievd from https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
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