HISTORY:
Cirrhosis follow-up
Progress since last visit:
Current symptoms:
Medications:
-
Adherence: ,
Social history:
Alcohol use: , drinks per
Smoking: , pack-years
Recreational drugs: ,
Diet: , , ,
Physical activity:
Weight: ,
Labs:
Liver function tests: AST: , ALT: , Alkaline phosphatase: , Bilirubin: , Albumin: , INR:
Renal function: Creatinine: , BUN:
Electrolytes: Na: , K: , Ca: , Mg:
CBC: Hemoglobin: , Platelets: , WBC:
Ammonia:
Alpha-fetoprotein (AFP):
Imaging: of the liver:
Esophagogastroduodenoscopy (EGD):
Vaccinations:
Hepatitis A:
Hepatitis B:
Influenza:
Pneumococcal:
Covid:
Complications:
Variceal bleeding:
Hepatic encephalopathy:
Spontaneous bacterial peritonitis:
Hepatocellular carcinoma:
Hepatorenal syndrome:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , , , ,
- Imaging: , ,
- Endoscopy:
- Liver biopsy
-
-
- for variceal bleeding prophylaxis
-
-
- Sodium restriction (<2g/day)
- Alcohol abstinence counseling
- Ascitic fluid paracentesis
- Vaccinations: , , , ,
- Referral to gastroenterologist
- Referral to hepatologist
- Follow-up in
- Return if symptoms worsen, such as increased abdominal girth, jaundice, confusion, or bleeding