Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a history of chronic liver disease, reporting progressive fatigue, abdominal distension, and unintentional weight loss. Review of systems positive for jaundice, pruritus, easy bruising, and pedal edema. Denies hematemesis, melena, or altered mental status. History significant for [Alcohol Use/Hepatitis B/C/NAFLD].
Clinical Examination Findings
Vitals stable. HEENT: Scleral icterus present. CV: Regular rate and rhythm. Resp: Clear to auscultation. Abd: Distended, positive fluid wave, shifting dullness, hepatosplenomegaly, non-tender. Ext: Bilateral 2+ pitting edema, palmar erythema, spider angiomata noted on chest/abdomen. Neuro: Alert and oriented x3, no asterixis.
Treatment Protocol
Initiate sodium restriction (<2g/day) and fluid restriction if hyponatremic. Prescribe diuretics (Spironolactone/Furosemide) for ascites management. Lactulose titration for encephalopathy prophylaxis. Schedule abdominal ultrasound and AFP screening for HCC surveillance. Refer to Hepatology for MELD score calculation and transplant evaluation.