Date:
Patient:
MRN:
Clincian: (Hepatologist, Hematologist)
Reason for Visit:
Evaluation for suspected or confirmed hepatic VOD
Review of laboratory results (liver function tests, bilirubin)
Assessment for symptoms and complications
Discussion of treatment plan
History of Present Illness:
Briefly describe the onset and progression of symptoms:
Right upper quadrant abdominal pain
Tenderness to palpation on abdominal exam
Nausea, vomiting
Jaundice (yellowing of the skin and eyes)
Ascites (fluid accumulation in the abdomen)
Recent history of hematopoietic stem cell transplantation (HSCT) or chemotherapy (common triggers)
Past Medical History:
Underlying medical condition requiring HSCT or chemotherapy
Previous episodes of VOD
Other relevant medical history (liver disease)
Social History:
Not typically relevant unless affecting overall health.
Physical Exam:
Vital Signs: May be normal or show signs of infection or fluid overload (elevated jugular venous pressure).
Abdominal exam:
Hepatomegaly (enlarged liver)
Right upper quadrant tenderness
Consider mentioning signs of ascites (increased abdominal girth, shifting dullness).
Consider mentioning signs of jaundice (icterus) on skin and sclerae.
Labs:
Liver function tests (LFTs):
Elevated bilirubin and liver enzymes are suggestive of liver dysfunction.
Coagulation studies:
May show abnormalities due to impaired liver function.
Consider mentioning other labs ordered as needed (renal function tests, electrolytes).
Imaging:
Imaging studies are not diagnostic for VOD but may be performed to rule out other causes of liver dysfunction or assess for complications (e.g., abdominal ultrasound for ascites).
Assessment:
Summarize the diagnosis of hepatic VOD based on clinical presentation (symptoms after HSCT/chemotherapy), physical exam findings, and characteristic laboratory abnormalities (elevated bilirubin).
Discuss the severity of VOD based on clinical criteria (Seattle criteria).
Plan:
Outline the treatment plan based on the severity of VOD:
Supportive care:
Intravenous fluids for hydration
Pain management medications
Nutritional support
Specific therapies for VOD:
Deflazacort (corticosteroid) may be used in some cases to suppress inflammation.
Extracorporeal membrane oxygenation (ECMO) may be considered in severe cases with life-threatening complications.
Consider mentioning the need for hospitalization for monitoring and management.
Prognosis:
Briefly discuss the prognosis. Prognosis depends on the severity of VOD, the underlying condition, and response to treatment. Early diagnosis and intervention are crucial to improve outcomes.
Education:
Document any education provided to the patient regarding:
The nature of hepatic VOD and its causes
The importance of early recognition and treatment
The potential side effects of medications
Warning signs and symptoms of complications (worsening abdominal pain, fever)
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, dietary restrictions, or the need for hospitalization.
Address the potential emotional impact of a serious illness and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hepatologist or hematologist for diagnosis, treatment recommendations, and prognosis.