Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: [Reason for visit – e.g., post-operative follow-up for liver transplant, new symptoms]
History of Present Illness:
Briefly describe the reason for this visit.
For follow-up visits, inquire about any new or worsening symptoms since the transplant (e.g., abdominal pain, fever, fatigue, signs of rejection).
For new symptom presentations, characterize them in detail (onset, duration, severity, aggravating/relieving factors).
Mention medication adherence to immunosuppressant medications.
Past Medical History:
Include the underlying liver disease that necessitated liver transplantation (e.g., cirrhosis due to hepatitis C).
Mention the date of the liver transplant surgery.
List any relevant past medical history (e.g., diabetes, hypertension).
Medications:
List all current medications, focusing on immunosuppressant medications used to prevent organ rejection.
Social History:
Briefly inquire about current alcohol and tobacco use (both contraindicated post-transplant).
Family History:
Not typically relevant for post-transplant care, but can be included if pertinent.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Abdominal exam: Assess for signs of abdominal tenderness, distension, or incisional healing.
Jaundice assessment: Look for signs of jaundice in the skin and sclerae (whites of the eyes).
Laboratory Tests:
Mention relevant laboratory findings, including:
Liver function tests (LFTs): Monitor for signs of rejection or recurrence of native liver disease.
Complete blood count (CBC): Assess for infection or anemia.
Tacrolimus or cyclosporine levels (if applicable): Monitor blood levels of immunosuppressant medications to ensure appropriate dosing and avoid rejection.
Imaging Studies (if performed):
Briefly describe findings from recent imaging studies, such as:
Doppler ultrasound: May be used to assess blood flow in the transplanted liver and identify complications like hepatic artery thrombosis.
Biopsy (if performed): Liver biopsy can be used to diagnose rejection.
Assessment:
Post-operative status: Briefly describe the patient’s recovery since the transplant surgery.
Immunosuppression regimen: Mention the current immunosuppressant medications and dosages.
Rejection status: Indicate if there is any evidence of acute or chronic rejection based on clinical presentation, laboratory tests, or biopsy results (if performed).
Complications: Mention any post-transplant complications, such as:
Infection: Increased risk due to immunosuppression.
Acute rejection: Immune system attack on the transplanted liver.
Chronic rejection: Gradual loss of function in the transplanted liver.
Biliary complications: Issues with bile drainage from the transplanted liver.
Plan:
Management:
Outline the plan for ongoing management, which may include:
Adjusting immunosuppressant medications to prevent rejection while minimizing side effects.
Monitoring for and treating any post-transplant complications.
Promoting healthy lifestyle habits to optimize overall health post-transplant.
Follow-up:
Schedule the next clinic visit for follow-up based on the patient’s condition and the need for monitoring.
Advise the patient to report any concerning symptoms promptly.