Taking a thorough history is the key to proper diagnosis, guides the patient encounter and directs necessary interventions and treatments, and perfecting this skill is particularly important in primary care.
A recent patient of mine presented with acute onset of right upper quadrant pain and tenderness. She was a new patient and had moved to the United States from Vietnam one-week prior. She denied any past medical history.
Liver function tests revealed that the patient’s aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated, despite normal results on the hepatitis panel and abdominal ultrasound.
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Evaluating abnormal hepatic enzymes is common in primary care practice. In order to accurately assess and develop the proper treatment plan for the patient that presents with this diagnosis, remember the following rules of thumb:
- AST increases with Alcohol, Statin or Tylenol use
- ALT increases with Alcohol, Liver Infection or Therapeutic agents (i.e. medications such as Troglitazone, an oral antihyperglycemic)
- If AST is elevated greater than ALT, the cause is likely alcohol inducedIf ALT is elevated greater than AST, the cause is likely infectious
By the time this patient returned for her follow-up appointment, the pain had resolved, but I pursued a more thorough history in hopes of identifying the cause of her elevated AST/ALT levels.
The patient denied past or present alcohol use, as well as any history of treatment for hyperlipidemia or diabetes. Liver infection had been ruled out, as her hepatitis panels were normal. However, when questioned about recent Tylenol use, the patient revealed that she had developed cold symptoms related to climate change that occurred during her move. In response she had consumed a large amount of Tylenol to relieve these symptoms, which explained the abnormal results on her liver tests.
Many patients expect health care providers to innately know how to address their concerns with little input on their part. I’ve found that the most successful patient-provider relationships are anchored in the expectation that both parties are stakeholders in ensuring optimal health. In my experience, this relationship begins with taking a thorough health history.
Leigh Montejo, MSN, FNP-BC, provides health care to underserved populations at the Metropolitan Community Health Service’s Agape Clinic in Washington, North Carolina.
