Cirrhosis follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a cirrhosis follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Current symptoms:

‍fatigue

‍jaundice

‍ascites

‍peripheral edema

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍confusion

‍hematemesis

‍melena, ‍withwithout strong foul smell

‍pruritus

‍anorexia

‍muscle cramps

‍easy bruising or bleeding



Medications:

- ‍

Adherence: ‍goodaveragepoor, ‍adverse effects



Alcohol use: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Recreational drugs: ‍none ‍cannabis, ‍IVDU



Diet: ‍goodaveragepoor, ‍low in salt, ‍high in carbs, ‍high in fat

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss



Labs: ‍unremarkable

Liver function tests: AST: ‍ ‍normal, ALT: ‍ ‍normal, Alkaline phosphatase: ‍ ‍normal, Bilirubin: ‍ ‍normal, Albumin: ‍ ‍normal, INR: ‍ ‍normal

Renal function: Creatinine: ‍ ‍normal, BUN: ‍ ‍normal

Electrolytes: Na: ‍ ‍normal, K: ‍ ‍normal, Ca: ‍ ‍normal, Mg: ‍ ‍normal

CBC: Hemoglobin: ‍ ‍normal, Platelets: ‍ ‍normal, WBC: ‍ ‍normal

Ammonia: ‍ ‍normal

Alpha-fetoprotein (AFP): ‍ ‍normal

Imaging: ‍UltrasoundCT scanMRI of the liver: ‍ ‍normalhepatomegalynodularityascites



Endoscopy:

Esophagogastroduodenoscopy (EGD): ‍ ‍normalvaricesgastritisulcers



Vaccinations:

Hepatitis A: ‍up-to-dateincompleteunvaccinated

Hepatitis B: ‍up-to-dateincompleteunvaccinated

Influenza: ‍up-to-dateincompleteunvaccinated

Pneumococcal: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated



Complications:

History of variceal bleeding: ‍yesno, ‍date of last episode

History of hepatic encephalopathy: ‍yesno, ‍date of last episode

History of spontaneous bacterial peritonitis (SBP): ‍yesno, ‍date of last episode

History of hepatocellular carcinoma (HCC): ‍yesno, ‍date of last diagnosis

History of hepatorenal syndrome: ‍yesno, ‍date of last episode





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Cirrhosis ‍likelysuspectedpossible

DDx: cirrhosis, alcoholic liver disease, chronic hepatitis B, chronic hepatitis C, non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis, hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, drug-induced liver injury, hepatic congestion (right heart failure), schistosomiasis, biliary atresia (in children), cryptogenic cirrhosis, portal hypertension, hepatocellular carcinoma





PLAN:

Investigations:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍LFTs, ‍INR, ‍albumin, ‍bilirubin, ‍ammonia, ‍alpha-fetoprotein, ‍viral hepatitis serologies

- Imaging: ‍abdominal ultrasound, ‍CT scan of abdomen, ‍MRI of abdomen

- Endoscopy: ‍esophagogastroduodenoscopy

- Liver biopsy

Treatments:

- ‍Diuretics

- ‍Lactulose

- ‍Non-selective beta-blockers for variceal bleeding prophylaxis

- ‍Vitamin supplements

- ‍Antibiotics

- Sodium restriction (<2g/day)

- Alcohol abstinence counseling

- Ascitic fluid paracentesis

- Vaccinations: ‍Hepatitis A, ‍Hepatitis B, ‍Pneumococcal, ‍Influenza, ‍Covid

Further care:

- Referral to gastroenterologist

- Referral to hepatologist

- Follow-up in ‍ ‍daysweeksmonths

- Return if symptoms worsen, such as increased abdominal girth, jaundice, confusion, or bleeding