Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s presenting symptoms, which can vary but may include:
Worsening jaundice (yellowing of the skin and eyes)
Encephalopathy (confusion, drowsiness, altered mental status)
Ascites (fluid buildup in the abdomen)
Hepatic encephalopathy (coma) – a severe complication
Gastrointestinal bleeding
History of Present Illness:
Onset and duration of new or worsening symptoms in a patient with known chronic liver disease.
Potential triggers for ACLF (e.g., alcohol abuse, new infection, medication overdose, gastrointestinal bleeding).
Past medical history (underlying chronic liver disease, previous hospitalizations for liver complications).
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be abnormal with fever, hypotension, or tachypnea (rapid breathing).
General examination: Assess for signs of dehydration, malnutrition, and jaundice.
Abdominal examination: Assess for ascites, hepatomegaly (enlarged liver), and splenomegaly (enlarged spleen).
Neurological examination: Assess for mental status, presence of asterixis (flapping tremor) – a sign of hepatic encephalopathy.
Laboratory Findings:
Liver function tests (LFTs): Marked abnormalities with elevated bilirubin, AST, ALT, and INR (prolonged clotting time).
Coagulation profile: Prolonged prothrombin time (PT) and INR suggest impaired clotting function.
Complete blood count (CBC): May show anemia or leukocytosis (high white blood cell count) if infection is present.
Electrolytes: May show abnormalities due to impaired liver function and kidney involvement.
Blood cultures: To rule out sepsis as a potential trigger.
Urinalysis: To assess for kidney function and rule out other causes of altered mental status.
Imaging Studies (may be ordered depending on presentation):
Ultrasound: Assess for ascites, liver size, and signs of portal hypertension.
Abdominal CT scan (with contrast): May be used in some cases to rule out other causes of abdominal pain or bleeding.
Assessment:
Diagnose acute-on-chronic liver failure (ACLF) based on clinical presentation, laboratory findings, and presence of at least two of the following criteria:
Encephalopathy
Jaundice
Ascites or evidence of portal hypertension
Identify the Model for End-Stage Liver Disease (MELD) score to assess disease severity and prognosis.
Determine the underlying chronic liver disease and potential triggers for ACLF.
Consider potential complications of ACLF (e.g., hepatic encephalopathy, variceal bleeding, hepatorenal syndrome).
Plan:
Address the underlying cause:
Management of infections with antibiotics.
Stopping alcohol or hepatotoxic medications.
Management of variceal bleeding if present.
Supportive care:
Fluid resuscitation for dehydration
Electrolyte and acid-base balance correction
Nutritional support (enteral or parenteral)
Lactulose for management of hepatic encephalopathy
Minimizing sedatives to prevent worsening encephalopathy
Consultations:
Hepatologist (specialist in liver diseases)
Gastroenterologist (for management of gastrointestinal bleeding)
Critical care medicine specialist (if severe ACLF with organ failure)
Progress Notes:
Document daily assessments including vital signs, mental status, presence of ascites, and response to treatment.
Note changes in laboratory results and imaging studies (if repeated).
Monitor for complications and adjust the plan as needed.
Discuss the possibility of liver transplantation with the patient and family if indicated.
Prognosis:
ACLF carries a high mortality rate, especially in severe cases.
Prognosis depends on the severity of ACLF, underlying cause, and presence of complications.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis, aggressive management, and consideration of liver transplantation are crucial to improve outcomes in ACLF.