Subjective
Date of visit
Reason for visit (initial evaluation for suspected portal vein thrombosis (PVT), follow-up for known PVT)
History of present illness:
Symptoms (may be absent or non-specific, especially early on):
Abdominal pain (right upper quadrant) – dull or aching
Nausea and vomiting
Fever (may be present)
Fatigue
Ascites (fluid accumulation in the abdomen) – develops in some cases
Splenomegaty (enlarged spleen) – may cause discomfort
Duration and progression of symptoms
Past medical history (relevant conditions):
Underlying conditions that increase PVT risk:
Abdominal surgery
Inflammatory bowel disease (IBD)
Liver cirrhosis
Pancreatitis
Sepsis
Hypercoagulable states (conditions that increase blood clot risk)
Previous history of PVT
Medications (current medications, anticoagulants if on treatment)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure) – may be elevated with inflammation or infection
Physical exam:
General (assessing for signs of chronic liver disease)
Abdominal exam:
Palpation for tenderness or hepatomegaly (enlarged liver)
Signs of ascites (shifting dullness on percussion)
Splenomegaly palpation (left upper quadrant mass)
Assessment
Suspected portal vein thrombosis based on clinical presentation and risk factors
Diagnostic workup (may include some of the following to confirm PVT and identify the underlying cause):
Laboratory tests:
Liver function tests (LFTs) – may show abnormalities suggestive of liver dysfunction
Complete blood count (CBC) – may show leukocytosis (elevated white blood cells) if there’s inflammation
Coagulation studies (may be abnormal)
Imaging studies:
Doppler ultrasound of the abdomen – the initial imaging modality to assess for PVT
CT scan or MRI with contrast (may provide more detailed information)
Plan
Definitive diagnosis of PVT and the underlying cause
Treatment (aimed at preventing clot extension, reducing portal hypertension, and addressing the underlying cause):
Anticoagulation therapy (blood thinners) – the mainstay of treatment for PVT
Management of ascites (dietary sodium restriction, diuretics) if present
Treatment of the underlying condition (if possible)
Education
Explain portal vein thrombosis, its causes, and potential complications (portal hypertension, variceal bleeding).
Discuss the importance of medication adherence and regular follow-up for monitoring.
Dietary modifications to manage ascites (if present).
Importance of recognizing and reporting signs of bleeding (hematemesis, melena).
Follow-up
Schedule for close follow-up appointments initially (weeks to months)
Monitor response to treatment (clinical improvement, imaging studies)
Adjust anticoagulation therapy as needed
Monitor for complications (bleeding, portal hypertension)
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 vein thrombosis.