Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: [Reason for visit – e.g., follow-up for cirrhosis, new symptoms like fatigue, abdominal pain]
History of Present Illness:
Briefly describe the reason for this visit.
For follow-up visits, inquire about any new or worsening symptoms since the last encounter (e.g., fatigue, abdominal pain, nausea, vomiting, jaundice, easy bruising, bleeding).
For new symptom presentations, characterize them in detail (onset, duration, severity, aggravating/relieving factors).
Past Medical History:
Include the known cause of liver cirrhosis (e.g., hepatitis C, alcoholic liver disease, non-alcoholic fatty liver disease).
Mention any previous complications of cirrhosis (e.g., ascites, esophageal varices, hepatic encephalopathy).
List any relevant past medical history (e.g., diabetes, hypertension).
Medications:
List all current medications, including those specifically for liver disease (e.g., diuretics for ascites, beta-blockers for esophageal varices, lactulose for hepatic encephalopathy).
Inquire about alcohol intake and adherence to dietary recommendations.
Social History:
Briefly inquire about current alcohol use (if applicable) and smoking habits.
Family History:
Mention any relevant family history of liver disease.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
General exam: Assess for signs of chronic liver disease (jaundice, spider angiomas, palmar erythema, gynecomastia).
Abdominal exam: Check for ascites (fluid accumulation), hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), and signs of variceal bleeding (hematemesis – vomiting blood, melena – black tarry stools).
Neurological exam: Assess for signs of hepatic encephalopathy (confusion, drowsiness, asterixis – flapping tremor).
Laboratory Tests:
Mention relevant laboratory findings, including:
Liver function tests (LFTs): May show abnormalities in bilirubin, AST, ALT, and albumin.
Coagulation profile: Prolonged prothrombin time (PT) and international normalized ratio (INR) may indicate increased bleeding risk.
Complete blood count (CBC): May show anemia due to impaired blood cell production in the liver.
Electrolytes: Abnormalities may be present due to fluid imbalance or complications like ascites.
Alpha-fetoprotein (AFP): May be elevated in some cases of cirrhosis and can suggest an increased risk of hepatocellular carcinoma (HCC).
Imaging Studies (if performed):
Briefly describe findings from recent imaging studies, such as:
Ultrasound: Can assess for ascites, hepatomegaly, splenomegaly, and signs of portal hypertension.
FibroScan (transient elastography): Non-invasive assessment of liver stiffness, which can indicate the degree of fibrosis.
CT scan or MRI: May be used to evaluate for complications or rule out other conditions.
Assessment:
Diagnosis: Confirm the diagnosis of liver cirrhosis and mention the known cause (e.g., cirrhosis due to hepatitis C).
Child-Pugh score: Briefly mention the Child-Pugh score if calculated, which helps assess the severity of liver dysfunction.
Complications: Identify any present or potential complications of cirrhosis, such as:
Ascites: Fluid accumulation in the abdomen.
Esophageal varices: Enlarged veins in the esophagus at risk of bleeding.
Hepatic encephalopathy: Altered brain function due to liver dysfunction.
Hepatorenal syndrome: Kidney dysfunction due to severe liver disease.
Hepatocellular carcinoma (HCC): Increased risk of liver cancer.
Plan:
Treatment:
Outline the treatment plan based on the severity of cirrhosis and presenting complications. This may include:
Management of the underlying cause: e.g., antiviral medications for hepatitis C.
Medications for complications: Diuretics for ascites, beta-blockers for esophageal varices, lactulose for hepatic encephalopathy.
Dietary recommendations: A balanced diet with sodium restriction if ascites is present.
Vaccination: Recommend vaccinations against hepatitis A and B to prevent further liver damage.
Liver transplant evaluation (if applicable): Consider referral for evaluation if the patient meets criteria and has severe complications.