HISTORY:
Presents for
Lab results:
ALT , AST , ALP , GGT
Bilirubin , Albumine , INR
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , , , , , , , , , , ,
- Blood work (advanced): , , , , , ,
- Abdominal ultrasound
- Liver biopsy
- Avoidance of alcohol
- Weight loss counseling
- Dietary modifications: ,
- Reassess medications that may be causing liver damage (acetaminophen, statins, antibiotics, antifungals, immunosuppressants, chemotherapy drugs, herbal supplements)
- Repeat LFTs in
- Referral to gastroenterologist
- Referral to hepatologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as jaundice, abdominal pain, or fever