Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 28-year-old woman with a longstanding history of injection drug use presents with a ten-day history of malaise, nausea, and fatigue, and a two-day history of “yellow eyes.” Physical exam reveals scleral icterus and mild hepatomegaly with right upper quadrant abdominal tenderness. Considering the possibility of acute hepatitis B in the differential, the NP anticipates the following lab results will include:
The correct answer here is D, the presence of hep B surface antigen. Where should you start? Given that this test item asks about the anticipated laboratory findings for a particular diagnosis, this question is focused on information gathering, it's an assessment question. And remember, when you're doing your differential, you are always thinking what additional information do I need to gather to contribute to the diagnosis?
Let's take a look at some background information. As you know, and you've heard me say many times in these podcasts, Q&As, success on boards springs off of having a solid sound knowledge base of commonly encountered conditions seen in primary care. Viral hepatitis is one of those diseases. Hepatitis is simply a general term for liver inflammation. What we're focusing in here is specifically hepatitis caused by a virus. A number of different viruses can invade the liver causing infection, but there are these hepatitis specific viral agents. In North America these viruses are as follows: The hepatitis A virus referred to as HAV, causing acute hepatitis A. By the way, there's no such thing as chronic hep A. Hepatitis B virus referred to as HBV, resulting in either acute or chronic hepatitis B. Hepatitis C virus referred to as HCV, resulting in acute or chronic hepatitis C. And the hepatitis D virus referred to as HDV, resulting in acute hepatitis D. In some parts of the world, other hepatitis specific viruses are found, and in particular, not found much in this country that probably should be more on our radar, but the hepatitis E virus is fairly common worldwide.
Hepatitis B is the focus of the question, and in future podcasts, I likely will go back and revisit some of the other liver specific viral infections. What is hepatitis B? It is a small double strand DNA virus that contains an inner core protein of hep B core antigen and an outside surface of hep B surface antigen. Hep B virus is usually transmitted through the exchange of blood and body fluid. Injection drug use, as mentioned in this patient scenario, really does pose a significant risk. That said, hep B, HBV, is often commonly transmitted via sexual activity as this virus is well concentrated in sexual fluid. This is, of course, a vaccine preventable disease. There is a highly effective immunization, it's offered routinely during childhood.
We are all health care providers. No doubt we have all been hepatitis B virus immunized. And this question, however, vaccination history is not mentioned. Therefore, one more time if it is not mentioned, it's not germane to the question. And what you have to do is say, okay, these are the data that I was given about the patient. I was told, what would you look for if this person had acute hep B, I will take it from there.
So, what is the clinical presentation of acute hepatitis B? Symptoms usually include malaise, myalgia, fatigue, nausea, and anorexia. When I see a person with acute hep B, I often think to myself, they are not acutely ill, like life-threateningly ill, but they are a big mess of miserable. They just feel awful and have often been like this woman dragging themselves around for more than a week before they come in to seek care. Sensitivity to certain smells, particularly tobacco smoke, is often reported. Common acute hepatitis B findings include right upper quadrant, abdominal tenderness, usually mild hepatomegaly but the hepatomegaly, a.k.a liver enlargement is actually only noted in about half the people. Point to keep in mind, absence of hepatomegaly does not exclude a diagnosis of acute hepatitis B.
Jaundice is not a universal finding, and when it does occur as it has in this patient, she's reporting, “yellow eyes.” We're told she has scleral icterus, so yellowing of the eyes. When it does occur, it usually occurs about a week after the onset of more general symptoms. She has felt poorly for about ten days, but her eyes have only been yellow for about two days. Very often that's what drives the person in for care. And they’ll go, Whoa, this is no good. Look at my yellow eyes. Clay colored stools are sometimes reported while dark colored urine is common. And what I've had patients describe to me with the dark colored urine is it looks like iced tea, a glass of Guinness stout, you know that really thick, thick beer, that type of thing. And what's staining the urine is actually bilirubin. And high bilirubin levels, of course, are what result in the scleral icterus, the jaundice. The duration of acute hepatitis B is around 2 to 3 weeks where people feel really poorly for about 2 to 3 weeks. And please keep in mind the clinical presentation of hep A, hep C and hepatitis D do differ. Is there some overlap with each of those? Yep, there is, but I'm going to leave it at that for right now. So, let's take a look at the question and the answer options.
We have a 28-year-old woman with a long-standing history of injection drug use presents with a ten-day history of malaise, nausea, fatigue, and a two day history of “yellow eyes.” Physical exam reveals scleral icterus and mild hepatomegaly with right upper quadrant abdominal tenderness. Considering the possibility of acute hepatitis B in the differential, the NP anticipates laboratory findings will include:
A. The presence of heavy surface antibody. This is incorrect. HbsAb, or hepatitis B surface antibody, also called anti-HBs, is known as a neutralizing antibody and its presence implies long-term immunity from infection with HBV. In other words, the serologic marker is only found in people who have either had hepatitis B in the past and are now immune. Hep B is a one and done disease, or in the vast majority of people who have had the hep B vaccine series. And it simply wouldn’t be found in a person with acute hepatitis B.
Option B. Thrombocytosis. This is also incorrect. Thrombocytosis, or an increased platelet count, is occasionally noted in individuals with a variety of acute illnesses, but it's a nonspecific finding. When you have a question like this, what you always want to go to is go to the most disease specific marker that is mentioned in the question.
Option C. Leukocytosis. Well, this is incorrect. Leukocytosis, or an elevation in the total WBC. This is a nonspecific finding that can be seen in a variety of different infections. Person with acute hep B might have this, but a variety of other infections can cause the number of white blood cells in circulation to increase.
Option D. The presence of hep B surface antigen. This is correct. Hep B surface antigen, abbreviated HBsAg, is the serologic hallmark of hepatitis B infection. After acquiring HBV, the hep B surface antigen appears in the serum within 1 to 10 weeks. Hepatitis B surface antigen is noted whenever the hep B virus is on board and usually clears as the disease resolves and hep B surface antibody rises. In acute hepatitis B, hep B surface antigen will be found, and it's accompanied by the signs and symptoms noted above, as well as markedly elevated, usually five times upper limits of normal or greater hepatic enzymes. Persistence of hep B surface antigen beyond six months from the onset of the initial acute hep B virus illness is noted with chronic hepatitis B. And this is usually in chronic hep B, the hepatic enzymes are mildly elevated, the person is without symptoms. About 5 to 10% of people who contract acute hep B infection will go on to develop chronic hep B. Now, please keep in mind those numbers are really, really different when we talk about infants, particularly neonates that pick up hep B virus through the birth process or even younger children who pick up hep B through whatever mechanism. And they have very, very, very high rates of chronic hepatitis B.
So key takeaway: Knowledge of the significance of common viral markers in hep B infection is critical to safe practice and certification success. Well, I know I just skimmed the surface here folks, and I only went over two serologic markers for hepatitis B. I went over the most important and the most revealing. So, the two in this question that are mentioned are simply the most clinically useful.
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