Date:
Patient:
MRN:
Clincian: (Hepatologist, Gastroenterologist, Intensivist) depending on severity
Reason for Visit:
Evaluation for suspected or confirmed hepatic encephalopathy
Assessment of mental status and neurologic function
Review of laboratory results (liver function tests, electrolytes, ammonia)
Discussion of treatment plan and management of underlying liver disease
History of Present Illness:
Briefly describe the onset and progression of symptoms:
Changes in mental status (confusion, lethargy, somnolence)
Asterixis (flapping tremor)
Speech abnormalities (slurring)
Personality changes (irritability, agitation)
Seizures (in severe cases)
Precipitating factors (dietary indiscretion, infection, bleeding)
Past medical history of liver disease (cirrhosis, hepatitis)
Past Medical History:
Underlying cause of liver disease (alcohol abuse, viral hepatitis, autoimmune hepatitis)
Previous episodes of hepatic encephalopathy
Other relevant medical history (renal dysfunction, electrolyte imbalances)
Social History:
Alcohol and substance abuse history (contributing factors)
Dietary habits (protein intake)
Medication adherence
Physical Exam:
Vital Signs: May be normal or show signs of infection or dehydration.
Neurologic exam:
Assess mental status (orientation, memory, attention).
Test for asterixis (flapping tremor).
Consider mentioning Glasgow Coma Scale (GCS) score for objective assessment of consciousness.
Consider mentioning other relevant physical exam findings (ascites, jaundice).
Labs:
Liver function tests (LFTs):
Elevated bilirubin and liver enzymes are suggestive of underlying liver disease.
Electrolytes:
Electrolyte imbalances (hyponatremia, hypokalemia) can worsen hepatic encephalopathy.
Ammonia level:
Elevated serum ammonia levels support the diagnosis of hepatic encephalopathy.
Consider mentioning other labs ordered as needed (coagulation studies, complete blood count).
Imaging:
Imaging studies are not diagnostic for hepatic encephalopathy but may be performed to investigate the underlying cause of liver dysfunction (e.g., ultrasound for liver cirrhosis).
Assessment:
Summarize the diagnosis of hepatic encephalopathy based on clinical presentation, neurologic examination, and potentially elevated ammonia levels.
Stage the severity of hepatic encephalopathy using a scoring system (West Haven criteria).
Identify the underlying cause of liver dysfunction.
Plan:
Outline the treatment plan based on the severity of hepatic encephalopathy:
Management of the underlying liver disease:
Address the cause of liver dysfunction (e.g., stopping alcohol intake, antiviral medications)
Consider mentioning specific medications for specific liver diseases.
Treatment of precipitating factors:
Correct electrolyte imbalances
Treat infections promptly
Dietary modifications (protein restriction)
Specific therapies for hepatic encephalopathy:
Lactulose: Non-absorbable sugar that promotes excretion of ammonia in the stool.
Rifaximin: Antibiotic that reduces ammonia-producing gut bacteria.
Consider mentioning other medications used in severe cases (e.g., L-ornithine-L-aspartate).
Consider mentioning the need for hospitalization for monitoring and management in severe cases.
Prognosis:
Briefly discuss the prognosis. Prognosis depends on the severity of hepatic encephalopathy and the underlying cause of liver disease. Early diagnosis and treatment are crucial to prevent complications.
Education:
Document any education provided to the patient and/or family regarding:
The nature of hepatic encephalopathy and its potential complications
The importance of managing the underlying liver disease
Dietary modifications and medication adherence
Warning signs and symptoms of worsening hepatic encephalopathy
The importance of seeking immediate medical attention for severe symptoms
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they or their family may have about medication side effects, dietary restrictions, or long-term management.
Address the potential emotional impact of cognitive decline and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hepatologist, gastroenterologist, or intensivist depending on the severity for diagnosis, treatment recommendations, and prognosis.