Patient profile and health history

The patient, Dr. Teresa Wilcox, is a 48-year-old European American female who is five feet six

inches tall and weighs one hundred and forty-five pounds. The female patient does not have

children, has not had any miscarriages and has been living with her husband for the past twenty

years. Her religious beliefs are Buddhism. She has a Doctoral degree and is a professor at a

university, where she teaches some afternoon and evening classes during semesters, weekends

also spent working. She has no know food allergies, consumes alcohol between one to three

times weekly. She stated that she has had no prior health issues, with the exception of being

postmenopausal, in the past thirty years and has no prior MNT^. She is currently taking 75 mg of

Wellbutrin, 60 mg of Allegra and 0,625/5mg of Prempro all of these medications are taken once

daily. In addition to taking these medications the patient is taking 400 mg of vitamin E, and 500

mg of a calcium multivitamin and mineral supplement. Her diet history consists of eating

breakfast at home, eating out for lunch and mostly eating Chinese food for dinner.

Overview of the disease

Hepatitis C originates from a single stranded RNA virus belonging to the family of Flaviviridae

(Maheshwari, 2008). Once infected the virus travels through the blood to the liver where it

begins to multiply. The bodys response to this are the release of natural chemicals. The liver is

unable to fight this virus and as it multiplies it kills liver cells and scares the organ, which in turn

causes inflammation. There are six genotypes for hepatitis C and all react to treatment

differently. The most common subtype is one, with approximately 70 to 90 percent of Americans

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who have hepatitis are infected with (Maheshwari, 2008). The less common subtypes are 2 and

3, with 10 to 20 percent of hepatitis infected persons are known to have. (Maheshwari, 2008)

Hepatitis C is transmitted through blood transfusions and needle pricks, also the use of dirty

needle. It has been found that sexually transmitted cases of hepatitis C are rare, but do occur.

Sharing a razor or something as simple as a tooth brush are other ways of an infected person

transmitting the disease. This disease is known as a silent but deadly disease as the symptoms are

asymptomatic during the acute phase. Many people live unaffected for years while their liver is

slowly being destroyed. When symptoms occur, they are somewhat flu like with signs of

anorexia, fatigue, itching and abdominal pain, usually in the right upper quadrant.

This disease can be prevented by testing blood that has been donated before preforming a

transfusion. Do not share needles. Before getting a tattoo look it would be wise to make sure the

parlor was following the rules set by the state in order to ensue clean needle practicing. Tattoo

artists are now regulated by law, they must follow precautionary steps in the prevention of the

spreading of disease designed by the CDC. If a person knows they are infected with the Hepatitis

C virus there are precautions to take in order not to spread the disease to others, one must be very

mindful when their blood is exposed.

Nutrition Assessment

The patients BMI is 23.4 the range being 18.5 to 24.9 for normal weight, her IBW is 133pounds.

The patient is in range for a healthy weight and because of her diagnosis a healthy weight needs

to be maintained... All of her lab values are in a normal range except for the liver enzyme and

blood pressure. The patients Bilirubin is 1.5mg/dl the normal rates being 0.2 to 1.3. Bilirubin is

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made during the breakdown of red blood cells which the liver helps secrete, high levels of this in

the blood can detect liver problems it can also cause jaundice. The ALT and AST results were

very high, ALT was 340 U/L and AST was 500 U/L These are both liver enzyme indicators they

are released into the blood at high levels when there is a liver infection usually a virus, ALT

being the better indicator for liver infections as AST is associated with other body organs such as

the heart and kidney and muscular system. The patients Alkaline Phosphate test was 302 U/L the

normal range being 98-251 U/L this enzyme found in the blood stream assists in the breakdown

proteins and is predominantly produced in the liver. LDH, lactic acid dehydrogenase an enzyme

aiding in the production of energy aids in the diagnosis of liver disease. The patients levels were

695 U/L compared to that of a normal range of 313-618 U/L. Blood pressure was documented as

being 100/60 mm Hg, this low number could be caused by dehydration from anorexia or from

infection. The patients skin was noted as being warm and dry, another sign of dehydration.

Examination of the patients head, eyes, ears, nose, throat as well as chest, lungs and pulse are all

within normal range, she is alert but is suffering from fatigue A recommendation of between

2000 and 2300 kcals per day has been recommended with 66 to 80 grams of protein Her twenty-

four-hour recall consisted of sips of orange juice, two servings of hot tea, four saltine crackers,

five cups of Jell-O. Twelve-ounce sprite and cream of chicken soup. The patient is allergic to

penicillin but has no know food allergies, just dislikes. Since being admitted to the hospital it has

been recommended by the dietitian that she receives a high protein diet. However, these

symptoms seem to be unspecific which makes the disease hard to diagnosis. Liver enzyme tests

are used to diagnosis, Bilirubin, ALT, AST and Alkaline Phosphate are all liver indicators and if

high show signs of infection but they cannot determine if the infection is caused by the hepatitis

virus. The HCV RNA test indicates if the disease is hepatitis C and how much of the virus is

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present in the liver. Once Hepatitis C has been detected the patient can be administered antiviral

medications which help prevent the spread of the hepatitis virus.

As of now antiviral medication are being used to treat Hepatitis C, but ongoing research is being

worked on for a potential vaccination and cure for the disease. Nutritionally one needs to eat a

healthy diet consisting of all food groups. No limitations are assigned to this diet with the

exception of Iron, as excess iron cannot be disposed of vitamin C helps absorb iron, too much

iron can further damage the liver causing hemochromatosis. It can also lead to diabetes and heart

defects. Vitamin B complex is an excellent supplement as it contains several different sources of

vitamin B that aid in detoxification and metabolism of food. Branched chain Amino Acids

consist of isoleucine, valine and leucine are another substitute for persons with hepatitis as its

catabolic disposal occurs in the muscle rather than the liver.

Medications

The patient was taking three medications as well as vitamin E and multi vitamins before

admission to the hospital. Wellbutrin is a medication primarily prescribed for depression, the

active ingredient being bupropion hydrochloride. There are several side effects that vary from

being very severe such as seizures, agitation, confusion and thoughts of suicide. Milder side

effects are headaches, dizziness, dry mouth and nausea. Allegra, an over the counter medication

for seasonal allergies, is an antihistamine. The active ingredient of this medication is

fexofenadine. The only risk of taking this drug, beside the minor side effects would be if a

person was suffering from kidney dysfunctions. Prempro 0.625/5 consist of 0.625 mg of estrogen

and 5 mg of medroxyprogesterone. This medication is often prescribed to women during or after

menopause. The three medications have no drug interactions that pertain to the patient.

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Since being hospitalized the patient has, beside her current medication, been taken off vitamin E

and multivitamins. The acting physician has prescribed 3MU Interferon Alfa-2b and Ribavirin to

be administered simultaneously. There are several side effects for these drugs that will affect the

patient nutritionally. Interferon alfa-2b, which will be administered by injection, has side effects

that pertain to the patient. They include depression, weight changes, dry mouth, and taste

deficiencies. There is a chance of seizures when taking serious nutritional side effects that should

be monitored include diarrhea, anorexia, nausea and vomiting. Ribavirin (Rebetol), which needs

to be taken along with interferon in order to be an effective treatment for the diagnosis of the

patient can cause anemia, anorexia, upset stomach, dry mouth, vomiting, diarrhea or

constipation. The severe effects include bloody stools, dark colored urine, and difficulty

swallowing and bloating of the stomach. Interferon alfa-2b and Ribavirin are medication used to

treat a hepatitis virus and are classified as antiviral medications. They do not cure this disease, as

there is not yet a cure, however they can slow the virus from spreading.

Long term plan

While the patient is in the hospital she can be monitored as to how well she is adapting to the new

medication as with the nutritional side effects.

The patient will need to learn how to focus on obtaining her kcal needs and protein needs. The focus is

eating for a healthy liver by omitting foods that contain unwanted toxins. The patient is being treated

with 3-MU interferon alfa-2b and Rebetol, both of which have nutritional side effects such as loss of

appetite, loss of taste and the possibility of nausea and vomiting. In order to overcome these obstacles

simple foods should be eaten several times daily. Several small meals should be consumed throughout

the day along with nutritious snacks. Snacks such as puddings, yogurt, peanut butter and crackers.

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Water and clear juices need to be consumed in order to stay hydrated. Beverages that contain caffeine

will not be a good source of fluids, water, apple and cranberry would be more appropriate. Beverages

that would aid in attaining protein and calories consist of milk, nutritional substitutes (in liquid form),

milkshakes and breakfast drinks.

There will be no specific times for the patient to eat. If nauseous in the morning dry toast or crackers

would be ideal to consume. There are no food restrictions for this disease but fried and spicy foods

should be avoided. The patient should avoid eating out, preparing a lunch and snacks to take to work

and preparing dinner at home. Grains, starchy vegetables, beans and lean meats are sources of protein.

Red meat is harder to break down therefore should be minimized but not be abstained from the diet.

Food labels are a good source of caloric information I order to maintain the caloric and protein needs.

The patient should keep a daily log of what is being eaten with the serving size of each item this will aid

in obtaining daily nutritional needs. Weekly weight should be taken as if there is weight loss the patient

should contact her attending physician.

Alternate Therapies

There are some alternative therapies for Hepatitis C as antiviral medications are very expensive. The first

therapy looked into was Silymarin also known as Milk Thistle this was used in several studies because of

the known fact that it acts as an antioxidant. (Fried, Navarro, Afdhal, & et.al., 2012). Studies were

conducted with persons having high levels of ALT a large dose was given to participants in conclusion

there was no evidence proving that high levels of ALT were decreases. (Fried, Navarro, Afdhal, & et.al.,

2012)

The second alternative therapy found was SNMC also known as Stronger Neominophagen C this major

ingredient of this is licorice root, cysteine, glycine and saline. (Services, 2005). This treatment is stated as

stabilizing hepatic membranes. A study was conducted showing that ALT and AST levels were lowered

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within four weeks but two weeks later proved there was no significant amount of evidence to show

these levels would stay within standard levels. (Services, 2005).

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 Questions

1. Several specific viruses are responsible for hepatitis symptoms. Describe the following characteristics

for each virus.

Answers are attached to the next page.

3. What signs and symptoms does Dr. Wilcox have?

The signs Dr. Wilcox is experiencing are. Low blood pressure, High ALT, AST, Bilirubin, Alkaline

phosphate and LDH (lactic acid dehydrogenase.

Her symptoms are fatigue, nausea, anorexia, aches and pains also upper right quadrant pain.

5. Examine the patients chemistry report. What values would steer Dr. Howard to the patients

diagnosis? What do these values measure and what is their relationship to liver disease?

The patient had high values of Bilirubin, ALT, AST, Alkaline Phosphate and LDH. High levels of bilirubin

can cause jaundice and it is a sign of liver problems. ALT and AST are liver enzymes, high values of these

indicate liver infection when released into the blood. Alkaline phosphate is mostly produced by the liver

for breaking down proteins, being at a high value associates liver infection. LHD aids in energy is high

when infection is present.

9. The course of the infection usually follows four phases. What are these? Which one is Dr. Wilcox in?

What is your rational?

Phase 1: The viral replication phase. Most patients are asymptomatic, when in this phase liver enzymes

are the only way to test for hepatitis

Phase 2: the prodromal phase. Patients in this phase have symptoms of nausea, anorexia, vomiting,

fatigue, taste alterations, malaise.

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Phase 3: the icteric phase. Patients have dark urine, pale colored stools gastrointestinal symptoms, pain

in upper right quadrant and may become jaundice.

Phase 4: The convalescent phase. The symptoms and jaundice settle. The liver enzymes return to

normal.

Dr. Wilcox is probably at the end stage of phase two and beginning of phase 3. She has all of the

symptoms for the second phase. She is experiencing right upper quadrant pain without the jaundice.

This is the explanation for her moving to the next phase.

17. Dr. Wilcox tells you that a friend suggests she use milk thistle to help fight the hepatitis virus. What

should you tell her?

Milk thistle is an herbal compound, it is made from the leaves of a Silybum Marianum plant. Its active

components are silybin, silydianin and silychristine. This herbal extract acts as an antioxidant. Research

has concluded that milk thistle has in no way cured hepatitis.

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 References

Fried, Michael W., MD., Navarro, Victor. MD., Afdhal, Nezam. MD., et.al. (July 18, 2012) Effect of

Silymarin (Milk Thistle) on Liver Disease in Patients with chronic Hepatitis C Unsuccessfully Treated

With Interferon Therapy Retrieved from: jamanetwork.com/journals/jama

Maasoumy, B., Wedemeyer, H. (2012). Natural History of Acute and Chronic Hepatitis.

Retrieved from: http://search.proquest.com/printviewfile?accountid+27927

Maheshwari, A., Ray, S., Thuluvath, P.J. (2005). AcuteHepatitis C. Retrieved from:

http://search.proquest.com/printviewfile?accountid=27927

United States Department of Health and Human Services (September, 2014). Alternative Therapies for

Hepatitis C. Retrieved from: inccam.nih.gov/health/silver Commented [GL1]:

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