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PATIENT PRESENTATION

Chief Complaint

“I want to get this Hepatitis C cured.”

History of Present Illness

PD is a 45-year-old Caucasian male who presents to the infectious diseases clinic seeking treatment for his chronic hepatitis C infection. He states that he was diagnosed with the disease a few years ago, but he’s not sure when he contracted it. He doesn’t remember having any symptoms related to the infection. He has never received any treatment for his hepatitis C.

Past Medical History

HTN, anxiety, dyslipidemia, GERD

Surgical History

None

Family History

Father and mother both alive with HTN and dyslipidemia; sister is alive with no known medical issues.

Social History

Former IV drug user and alcohol drinker, but clean and sober for 7+ years. No tobacco. Works repairing wheelchairs and scooters. Married with 2 children (12 and 4 years). Enjoys playing sports and doing outdoor activities with wife and children.

Allergies

NKDA

Home Medications

Amlodipine 10 mg PO daily

Alprazolam 1 mg PO TID PRN for anxiety

Simvastatin 20 mg PO daily

Omeprazole 40 mg PO daily

Multivitamin PO daily

Acetaminophen 325 mg PO PRN for headache

Physical Examination

Vital Signs

Temp 98.8°F, P 82 bpm, RR 18 breaths per minute, BP 127/78 mm Hg, pO2 99%, Ht 6′, Wt 101 kg

General

Normal appearing male in no apparent distress, well groomed

HEENT

Nomocephalic, atraumatic, PERRLA, EOMI, b/l sclera anicteric, moist mucous membranes, poor dentition

Pulmonary

Clear to auscultation, no use of accessory muscles, no cracks or wheezes

Cardiovascular

NSR, no m/r/g

Abdomen

Soft, non-distended, non-tender, normal bowel sounds

Genitourinary

Normal male genitalia, no complaints of dysuria or hematuria

Neurology

Alert and oriented × 3, CN 2-12 grossly intact

Extremities

No edema, cyanosis, or clubbing

Skin

Intact, w/o rashes or lesions, or erythema

Laboratory Findings

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WBC: 6 × 109 cells/L

Glucose: 80 mg/dL

Albumin: 3.8 mg/dL

Hgb: 15 g/dL

BUN: 15 mg/dL

T bili: 0.8 mg/dL

Hct: 45%

SCr: 0.9 mg/dL

AST/ALT: 50 IU/L / 50 IU/L

Plts: 102,000/mmol

K: 4 mEq/L

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