Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
This section will vary depending on the severity of INPH. Common symptoms may include:
Ascites (abdominal fluid accumulation)
Variceal bleeding (bleeding from enlarged esophageal or gastric veins)
Portal hypertension encephalopathy (confusion, memory problems) – severe complication
Abdominal pain or discomfort
Early satiety (feeling full after eating a small amount)
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at onset of symptoms
Duration and severity of symptoms
Presence of any bleeding episodes (severity, location)
History of hospital admissions for complications of INPH (e.g., ascites, variceal bleeding)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that may be associated with INPH (e.g., autoimmune diseases, systemic infections)
Prior surgeries or procedures (abdominal surgeries may increase risk)
History of blood clots
家族史 (jiā zú shǐ) Family History:
Family history of liver disease (uncommon)
社会史 (shè huì shǐ) Social History:
Alcohol consumption
Use of tobacco or other recreational drugs
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show signs of infection)
General appearance (evidence of ascites, malnutrition)
Abdominal exam:
Ascites (fluid wave)
Splenomegaly (enlarged spleen)
Hepatomegaly (enlarged liver – uncommon in INPH)
Signs of varices (on endoscopy)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Liver function tests (LFTs) – may be normal or mildly abnormal in INPH
Complete blood count (CBC) – may show anemia
Coagulation studies (assessing blood clotting function)
Viral serologies (to rule out viral hepatitis)
Autoimmune markers (depending on suspicion)
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Ultrasound of the abdomen:
May show ascites, splenomegaly, and assess for portal vein size and blood flow.
Doppler ultrasound of the portal vein:
May show signs of portal hypertension (increased portal vein velocity)
Abdominal CT scan with contrast (if ultrasound inconclusive):
Can visualize the liver, spleen, and portal vein in more detail.
Endoscopy (esophagogastroduodenoscopy – EGD):
Essential to assess for the presence and severity of esophageal varices.
Other Investigations (depending on suspicion):
Liver biopsy (to rule out other liver diseases)
Cardiac catheterization (to rule out Budd-Chiari syndrome – a rare cause)
诊断 (zhěn duàn) Diagnosis:
Idiopathic noncirrhotic portal hypertension (based on clinical presentation, exclusion of liver disease, and characteristic imaging findings)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Management of ascites:
Diuretics (spironolactone)
Paracentesis (removal of abdominal fluid with a needle)
Prevention of variceal bleeding:
Endoscopic variceal band ligation (EVL)
Beta-blockers (to reduce portal pressure)
Treating underlying conditions: If a specific cause of INPH is identified, treatment for that condition may be helpful.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of INPH, presence of complications, and response to treatment.
Early diagnosis and treatment are crucial to prevent complications like variceal bleeding. Regular follow-up is essential to monitor for complications and adjust treatment as needed.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following a low-sodium diet to manage ascites
Importance of medication adherence
Recognizing signs of variceal bleeding (hematemesis – vomiting blood, melena – black stools) and seeking immediate medical attention.
Importance of regular follow-up appointments with a gastroenterologist or hepatologist
Avoiding alcohol and certain medications that can worsen portal hypertension
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of INPH and response