Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of long-term Methotrexate (MTX) therapy. Reports [no/mild] fatigue, RUQ discomfort, or jaundice. Cumulative MTX dose is [X] mg. Adherence to folic acid supplementation is [confirmed/suboptimal]. No history of alcohol abuse or concurrent hepatotoxic medication use. Current LFTs show [stable/elevated] transaminases.
Clinical Examination Findings
General: Patient appears [well-nourished/chronically ill]. HEENT: Scleral icterus [absent/present]. Abdomen: Soft, non-tender, [no/palpable] hepatomegaly. Liver span [X] cm. No stigmata of chronic liver disease (spider angiomata, palmar erythema, caput medusae). Extremities: No peripheral edema.
Treatment Protocol
Plan: 1. Discontinue Methotrexate immediately due to evidence of hepatic fibrosis. 2. Initiate hepatology consultation for liver biopsy or non-invasive fibrosis assessment (FibroScan/ELF test). 3. Monitor LFTs and prothrombin time. 4. Switch to alternative DMARD therapy as indicated by rheumatology. 5. Strict avoidance of hepatotoxins, including alcohol.