Subjective
Date of visit
Reason for visit (follow-up for PBC, evaluation of new symptoms)
Current symptoms:
Fatigue (a common and often debilitating symptom)
Pruritus (itching, a hallmark symptom of PBC)
Right upper quadrant abdominal pain (may be present)
Xanthomas (yellowish skin deposits) – can occur in some patients
Dryness (eyes, mouth)
Fatty food intolerance (may develop)
Bone pain or fractures (potential complications)
Cognitive difficulties (less common)
Changes in bowel habits (diarrhea or constipation)
Changes in urine color (darkening)
Recent changes in medications or health
Stressful events since last visit
Objective
Vital signs (temperature, blood pressure, heart rate)
Physical exam:
General (assessing for signs of liver disease – jaundice, ascites)
Skin (looking for signs of jaundice, excoriations from scratching)
Abdomen (palpating for liver size and tenderness)
Laboratory Tests
Liver function tests (LFTs):
Elevated alkaline phosphatase (ALP) – a hallmark finding in PBC
Elevated bilirubin (may be present)
Elevated liver enzymes (AST, ALT)
Antimitochondrial antibody (AMA): positive in >90% of PBC patients (diagnostic test)
Lipid panel: may show elevated cholesterol or triglycerides
Complete blood count (CBC) – may show low white blood cell count
Imaging Tests (may be ordered depending on clinical presentation):
Liver ultrasound: to assess liver size and structure
FibroScan (non-invasive test): to assess liver fibrosis
Liver biopsy (definitive test for PBC, but not routinely performed)
Assessment
Primary biliary cholangitis (confirmed or suspected based on clinical presentation, laboratory findings)
Stage of disease progression (based on liver function tests and other investigations)
Presence of complications (e.g., osteoporosis, malnutrition, liver cirrhosis)
Plan
Treatment plan based on disease stage and symptoms:
Ursodeoxycholic acid (UDCA) – the mainstay of treatment to improve bile flow and liver function
Antihistamines and bile acid sequestrants (to manage pruritus)
Fat-soluble vitamin supplementation (vitamins A, D, E, K) – as these vitamins may be poorly absorbed
Calcium and vitamin D supplementation (to prevent osteoporosis)
Referral to a liver specialist (if needed) for complex cases or consideration of liver transplantation (in end-stage disease)
Education
Explain primary biliary cholangitis, a chronic autoimmune liver disease.
Discuss the treatment plan, potential side effects, and importance of medication adherence.
Importance of a healthy lifestyle with a balanced diet and regular exercise.
Management strategies for pruritus (itching) and other symptoms.
Importance of regular follow-up to monitor disease progression and potential complications.
Provide information about support groups or patient advocacy organizations.
Follow-up
Schedule for follow-up appointments:
Monitor response to treatment (symptoms, laboratory tests)
Adjust medication regimen as needed
Address any ongoing challenges or concerns
Screen for complications (bone density scans)
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 primary biliary cholangitis.