Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
Symptoms:
Pruritus (severity, location, duration)
Fatigue
Nausea/Vomiting
Loss of appetite
Abdominal pain (location, character)
Dark urine
Pale stools
Jaundice (present/absent)
Onset and Progression of Symptoms:
When did symptoms first begin?
Have symptoms worsened, improved, or remained stable?
Treatment History:
Medications for pruritus (type, dosage, effectiveness)
Other medications
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Jaundice (present/absent)
Skin: Excoriations (scratches) from itching
Abdomen: Palpable liver (size, tenderness)
Labs:
Liver function tests (LFTs): Bilirubin, AST, ALT, ALP
Bile acids (total and specific)
Assessment:
Intrahepatic cholestasis of pregnancy (ICP)
Plan:
Continue/adjust medications:
Ursodeoxycholic acid (UDCA) – dosage adjustment based on labs
Additional medications for pruritus if needed
Labs:
Monitor LFTs and bile acids every [frequency] weeks.
Fetal monitoring:
Non-stress test (NST) or biophysical profile (BPP) every [frequency] weeks, more frequently if indicated.
Delivery considerations:
Discuss potential for early delivery if severe symptoms or fetal compromise.
Education:
Provide patient education on ICP, management strategies, and potential risks.
Encourage good skin care to prevent infection from scratching.
Advise on healthy diet and importance of maintaining hydration.
Follow-up:
Schedule next appointment in [interval] weeks.