Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Document current symptoms suggestive of liver dysfunction:
Fatigue
Loss of appetite
Nausea or vomiting
Abdominal pain or right upper quadrant tenderness
Dark urine
Jaundice (yellowing of the skin and eyes)
Inquire about the timing of symptom onset in relation to medication initiation or dose changes.
Ask about current medications, including herbal supplements and over-the-counter drugs.
Objective:
Vital Signs: Include heart rate, blood pressure, temperature (elevated temperature may suggest viral hepatitis).
Physical Exam:
General: Assess for signs of jaundice, scleral icterus (yellowing of the whites of the eyes), ascites (fluid accumulation in the abdomen).
Abdominal: Evaluate for hepatomegaly (enlarged liver), palpable liver edge, right upper quadrant tenderness.
Labs:
Liver function tests (LFTs):
ALT (alanine aminotransferase)
AST (aspartate aminotransferase)
Alkaline phosphatase (ALP)
Bilirubin (total and direct)
Other labs as indicated:
Complete blood count (CBC) with differential
Coagulation studies (prothrombin time (PT), INR)
Viral serologies (hepatitis A, B, C)
Assessment:
Suspected drug-induced liver injury (DILI) based on:
Clinical presentation (symptoms suggestive of liver dysfunction)
Temporal relationship to medication use
Exclusion of alternative etiologies (viral hepatitis, alcoholic liver disease, autoimmune hepatitis) – consider laboratory findings and clinical course.
Severity of DILI using scoring systems (e.g., Ruch score, Maddrey score) if applicable.
Plan:
Identification and Management of the Causative Agent:
Review current medications and identify potential hepatotoxic agents.
Discontinue the suspected offending medication(s) whenever possible.
Supportive Care:
Maintain hydration with intravenous fluids if needed.
Monitor electrolytes and coagulation studies closely.
Consider medications to manage nausea and vomiting.
Consultation: Consider consulting with a gastroenterologist or hepatologist for complex cases or severe DILI.
Follow-up:
Repeat LFTs frequently to monitor liver function recovery.
Schedule close follow-up visits to assess clinical improvement and adjust treatment plan as needed.
Document the DILI episode in the patient’s medical record for future reference.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant information regarding symptoms, risk factors, laboratory findings, assessment of DILI severity, and treatment plan.