Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with clinical evidence of cholestatic drug-induced liver injury (DILI). Symptoms include jaundice, pruritus, dark urine, and pale stools. Onset correlated with initiation of [Medication Name] [Number] weeks/months ago. Denies abdominal pain, fever, or history of biliary obstruction. No history of alcohol abuse or viral hepatitis exposure.
Clinical Examination Findings
General: Patient appears jaundiced; no acute distress. HEENT: Scleral icterus present. Abdomen: Soft, non-tender, non-distended. Liver span [Number] cm, no palpable hepatomegaly. No splenomegaly or shifting dullness. Skin: Excoriations noted secondary to pruritus; no spider angiomata or palmar erythema.
Treatment Protocol
1. Immediate discontinuation of the offending agent: [Medication Name]. 2. Supportive care: Ursodeoxycholic acid [Dose] mg TID for cholestasis. 3. Pruritus management: Antihistamines or cholestyramine as indicated. 4. Monitor LFTs (ALP, GGT, Bilirubin) weekly. 5. Avoid hepatotoxic substances including alcohol and herbal supplements.