Subjective
Date of visit
Reason for visit (initial evaluation for suspected portal hypertension, follow-up for known portal hypertension)
History of present illness:
Symptoms (may be absent in early stages):
Gastrointestinal bleeding (hematemesis – vomiting blood, melena – black tarry stools) – most serious complication
Ascites (fluid accumulation in the abdomen) – causing abdominal distension and discomfort
Esophageal varices (enlarged veins in the esophagus) – can rupture and cause life-threatening bleeding
Splenomegaly (enlarged spleen) – may cause discomfort in the left upper abdomen
Fatigue
Loss of appetite
Duration and progression of symptoms
Past medical history (relevant conditions):
Liver disease (cirrhosis is the most common cause)
Portal vein thrombosis
Schistosomiasis (parasitic infection)
Budd-Chiari syndrome (obstruction of hepatic veins)
Medications (current medications, diuretics for ascites)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure) – may be abnormal depending on complications (e.g., infection, bleeding)
Physical exam:
General (assessing for signs of chronic liver disease – jaundice, spider angiomas)
Abdominal exam:
Ascites palpation (shifting dullness on percussion)
Splenomegaly palpation (left upper quadrant mass)
Rectal exam (may reveal hemorrhoids)
Signs of encephalopathy (confusion, asterixis – flapping tremor) may be present in severe cases.
Assessment
Suspected portal hypertension based on clinical presentation and risk factors
Diagnostic workup (may include some of the following to confirm the diagnosis and identify the underlying cause):
Laboratory tests:
Liver function tests (LFTs) – may show abnormalities suggestive of liver disease
Complete blood count (CBC) – may show anemia
Coagulation studies (may be abnormal)
Imaging studies:
Ultrasound of the abdomen (to assess for ascites, splenomegality, and portal vein patency)
CT scan or MRI (may provide more detailed information)
Endoscopy (esophagogastroduodenoscopy – EGD) – to visualize esophageal varices
Plan
Definitive diagnosis of the underlying cause of portal hypertension
Treatment (aimed at managing symptoms, preventing complications, and addressing the underlying cause):
Management of ascites:
Dietary sodium restriction
Diuretics (spironolactone)
Prevention of variceal bleeding:
Endoscopic variceal band ligation (EVL)
Beta-blocker medications (non-selective) to reduce portal pressure
Treatment of the underlying liver disease (if possible)
Education
Explain portal hypertension, its causes, and potential complications.
Discuss the importance of medication adherence and regular follow-up.
Dietary modifications to manage ascites (sodium restriction).
Signs and symptoms of variceal bleeding to report promptly (hematemesis, melena).
Follow-up
Schedule for close follow-up appointments initially, then gradually less frequent as controlled
Monitor for complications (bleeding, encephalopathy)
Repeat imaging studies periodically to assess response to treatment
Consider referral to a hepatologist (liver specialist) for complex cases or complications
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of portal hypertension.