Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of known metastatic breast cancer with recent imaging confirming hepatic involvement. Reports [stable/worsening] RUQ discomfort, early satiety, and fatigue. Denies jaundice, acholic stools, or acute abdominal pain. Current systemic therapy: [Insert Regimen]. ECOG performance status: [0-4].
Clinical Examination Findings
General: Patient appears [well/chronically ill]. HEENT: Sclerae anicteric. Abdomen: Soft, non-tender, hepatomegaly noted with [smooth/nodular] edge palpable [X] cm below the right costal margin. No shifting dullness or fluid wave. Extremities: No peripheral edema. Skin: No spider angiomata or palmar erythema.
Treatment Protocol
Plan: 1. Continue systemic therapy: [Insert Chemotherapy/Endocrine/Targeted Therapy]. 2. Monitor LFTs and CBC every [X] weeks. 3. Repeat abdominal imaging (CT/MRI) in [X] months to assess treatment response per RECIST criteria. 4. Supportive care: Pain management as needed, nutritional support, and oncology nursing follow-up.