Case Study on Bertha

Case Study on Bertha

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.

Past medical history: 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.

Allergies: No known drug or food allergies.

Case Study on Bertha

OBJECTIVE General appearance: 58 – year – old female; pleasant, in no acute distress; good eye contact. Vital signs: T: 96.8; P: 76; RR: 25; SaO 2 : 91; BP: 138/80. Her weight is 174 lb, and her height is 63 inches.

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

Cardiovascular: Regular rate and rhythm. Apical Pulse (PMI) is at 5th intercostal space, left sternal border. Pulses + 2 all extremities.

Respiratory: Lungs clear to auscultation, No wheezes; no crackles.

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

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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 emergent referrals needed?

Case Study on Bertha

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.

Past medical history: 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.

Allergies: No known drug or food allergies.