Date:
Patient:
MRN:
Attending Physician:
Reason for Visit:
New diagnosis of EHPVO
Follow-up for EHPVO
Evaluation of treatment response
Management of complications
History of Present Illness:
Briefly describe the patient’s presentation:
Onset and duration of symptoms (abdominal pain, ascites, variceal bleeding, fatigue)
Severity of symptoms
Prior hospitalizations for complications
Past Medical History:
Include any relevant past medical conditions that may contribute to EHPVO, such as:
Abdominal trauma (past surgery, blunt injury)
Pancreatitis
Abdominal infections
Tumor invasion (malignant causes of EHPVO)
Congenital anomalies (less common)
Social History:
Tobacco use (current and past)
Alcohol use
Family History:
History of blood clotting disorders in first-degree relatives (may be a risk factor for EHPVO secondary to thrombosis)
Physical Exam:
General: Appearance of illness, signs of chronic liver disease (jaundice, spider angiomas), ascites, evidence of variceal bleeding (hematemesis, melena).
Vital Signs: Temperature, pulse, blood pressure
Abdomen: Distension, tenderness, hepatomegaly, splenomegaly
Labs:
List recent laboratory tests:
Liver function tests (may show abnormalities suggestive of liver dysfunction)
Complete blood count (CBC) – may show anemia if bleeding has occurred
Coagulation profile (evaluate for clotting abnormalities)
Consider mentioning other tests as relevant, such as tumor markers (if malignancy suspected).
Imaging:
Mention recent imaging studies:
Doppler ultrasound (initial diagnostic test to visualize portal vein thrombosis or obstruction)
CT scan with portal venography (provides detailed images of portal vein anatomy)
MRI scan (may be used to assess for specific causes of EHPVO)
Assessment:
Confirm the diagnosis of EHPVO based on imaging studies.
Identify the underlying cause of EHPVO (if possible).
Assess the severity of portal hypertension based on clinical features and imaging findings.
Evaluate for complications of EHPVO, such as ascites, variceal bleeding, and hepatic encephalopathy.
Plan:
Outline the treatment plan based on the cause and severity of EHPVO:
Addressing the underlying cause:
Anticoagulation for thrombosis-related EHPVO
Surgery (may be an option in specific cases to remove the obstruction)
Treatment of malignancy (if applicable)
Management of portal hypertension:
Medications (beta-blockers, diuretics) to reduce portal pressure
Endoscopic variceal band ligation (EVL) to prevent variceal bleeding
Transjugular intrahepatic portosystemic shunt (TIPS) procedure (considered in specific cases)
Management of complications (diuretics for ascites, lactulose for hepatic encephalopathy)
Prognosis:
Briefly discuss the patient’s prognosis, which depends on the underlying cause, severity of portal hypertension, and response to treatment.
Education:
Document any education provided to the patient regarding:
The nature of EHPVO and its complications
Importance of medication adherence
Dietary modifications (may be recommended to reduce risk of bleeding)
Warning signs and symptoms of complications
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and emotional well-being.
Consider mentioning the need for lifelong follow-up and monitoring for complications.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.