Hepatology Liver Disease Consult Note

Chief Complaint: Patient reports persistent fatigue and intermittent right upper quadrant abdominal pain for the past six months. History of Present Illness: Mrs. Jane Doe, a 55-year-old female, presents with a 6-month history of progressive fatigue, often debilitating, which interferes with her daily activities. She also experiences intermittent, dull right upper quadrant abdominal pain, which she rates 4/10 in severity, occurring approximately 3-4 times a week. The pain is not related to meals and is not relieved by over-the-counter analgesics. She denies fever, chills, nausea, vomiting, or jaundice. She has noticed a gradual increase in abdominal girth over the last two months and occasional ankle swelling, predominantly in the evenings. She reports a 5 kg unintentional weight loss over the past year. Her appetite has decreased slightly. **Significant fatigue and unexplained weight loss alongside abdominal discomfort and increasing abdominal girth are concerning for underlying liver pathology.** Past Medical History: Diabetes Mellitus Type 2 (diagnosed 10 years ago, managed with Metformin), Hypertension (controlled with Amlodipine), Obesity (BMI 32), Hyperlipidaemia (controlled with Atorvastatin). No prior history of viral hepatitis, autoimmune conditions, or malignancy. No history of transfusions. **Significant past medical history includes Diabetes, Hypertension, and Obesity, all major risk factors for Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH).** Medications: Metformin 500 mg BID, Amlodipine 5 mg OD, Atorvastatin 20 mg OD. She denies taking any over-the-counter supplements or herbal remedies. She occasionally takes paracetamol for headaches, not exceeding recommended dosages. **No overtly hepatotoxic medications identified; however, polypharmacy in the context of metabolic syndrome warrants careful consideration.** Social History: Patient reports consuming 2-3 units of alcohol per week (mostly wine) for the past 20 years, which she describes as social drinking. Denies tobacco use. Denies recreational drug use. Works as an accountant, no known occupational exposures. No significant travel history outside the UK. **Alcohol intake is moderate, but combined with metabolic risk factors, could contribute to liver disease progression.** Family History: Mother had Type 2 Diabetes and Hypertension. Father died of myocardial infarction. No known family history of liver disease, autoimmune conditions, or metabolic disorders such as haemochromatosis or Wilson's disease. **No significant family history of liver disease.** Review of Systems: General: Significant fatigue, 5 kg unintentional weight loss. Denies fever, chills, night sweats. Cardiovascular: Denies chest pain, palpitations. Occasional ankle swelling. Pulmonary: Denies shortness of breath, cough. Gastrointestinal: Intermittent RUQ pain, decreased appetite, increased abdominal girth. Denies nausea, vomiting, diarrhoea, constipation. No dark urine or light stools. No jaundice. Dermatological: Denies pruritus, skin rashes, easy bruising. Neurological: Denies confusion, headaches, tremors. **Positive findings include significant fatigue, unintentional weight loss, intermittent RUQ pain, increased abdominal girth, and ankle swelling, all suggestive of potential liver dysfunction or decompensation.** Physical Examination: Vital Signs: BP 130/80 mmHg, HR 78 bpm, RR 16 bpm, Temp 36.8°C, SpO2 98% on room air. BMI 32 kg/m². General appearance: Chronically unwell, slightly jaundiced sclera noted upon close inspection. HEENT: Scleral icterus present. No spider angiomata on face or neck. Cardiovascular: S1/S2 heard, no murmurs. Pulmonary: Clear to auscultation bilaterally. Abdominal examination: Abdomen distended, positive fluid thrill, shifting dullness present suggestive of moderate ascites. Liver edge palpable 4 cm below costal margin, firm, non-tender. Spleen not palpable. Extremities: Bilateral pitting oedema up to mid-shin. Skin: No spider angiomata on trunk, no palmar erythema. Capillary refill < 2 seconds. **Abnormal physical findings include scleral icterus, abdominal distension with ascites, hepatomegaly (firm liver edge), and bilateral pitting oedema, all highly suggestive of advanced liver disease and portal hypertension.** Laboratory Data: Collected on 1 November 2024: ALT 120 U/L (Ref < 40 U/L), AST 95 U/L (Ref < 40 U/L), Alkaline Phosphatase 180 U/L (Ref 40-129 U/L), Total Bilirubin 3.5 mg/dL (Ref < 1.2 mg/dL), Direct Bilirubin 2.8 mg/dL, Albumin 2.8 g/dL (Ref 3.5-5.0 g/dL), PT 18 seconds (Ref 10-13 seconds), INR 1.5, Platelets 110 x 10^9/L (Ref 150-450 x 10^9/L), Hb 10.5 g/dL (Ref 12-15 g/dL). Comprehensive Metabolic Panel shows low sodium (130 mmol/L) and elevated creatinine (1.2 mg/dL). Additional tests: HBsAg negative, Anti-HCV negative, ANA negative, Anti-SMA negative, Ferritin 450 ng/mL. **Significantly abnormal laboratory values include elevated liver enzymes (ALT, AST, ALP), hyperbilirubinemia (predominantly direct), hypoalbuminaemia, coagulopathy (prolonged PT/INR), thrombocytopaenia, anaemia, hyponatremia, and elevated creatinine. These indicate significant hepatocellular injury, impaired synthetic function, portal hypertension, and early renal impairment.** Imaging: Abdominal Ultrasound (performed 1 week prior): Liver appears enlarged with a nodular contour, suggestive of cirrhosis. Diffuse increased echogenicity consistent with steatosis. Splenomegaly (15 cm). Moderate ascites identified. Portal vein diameter 13 mm with reduced flow velocity. No focal liver lesions identified. **Abnormal imaging findings include sonographic evidence of cirrhosis, steatosis, splenomegaly, and moderate ascites, confirming advanced liver disease and portal hypertension.** Assessment and Plan: This 55-year-old female presents with clinical and biochemical evidence of decompensated liver cirrhosis, likely secondary to Non-Alcoholic Steatohepatitis (NASH) given her history of Diabetes, Hypertension, and Obesity. The patient exhibits features of portal hypertension including ascites, splenomegaly, and coagulopathy. Her symptoms of fatigue, RUQ pain, and unintentional weight loss, combined with signs of jaundice, ascites, and oedema, are concerning. The laboratory findings of elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia, and prolonged PT/INR further support the diagnosis of decompensated cirrhosis. The abdominal ultrasound findings are consistent with cirrhosis and portal hypertension. Differential diagnoses include alcoholic liver disease (less likely given reported alcohol intake but not entirely excluded), autoimmune hepatitis (serology negative), viral hepatitis (serology negative), and less commonly, genetic hemochromatosis or Wilson's disease (initial screening tests not strongly suggestive, but further work-up may be warranted). Management recommendations include further diagnostic workup to confirm etiology and assess severity. This will involve FibroScan or liver biopsy to stage fibrosis, alpha-fetoprotein (AFP) for hepatocellular carcinoma screening, and comprehensive autoantibody panel. Lifestyle modifications will be crucial, focusing on strict diabetic control, weight reduction through dietary changes and exercise, and continued alcohol abstinence. Medications will need to be reviewed; diuretics will be initiated for ascites management. Patient education regarding the progression of liver disease, dietary restrictions (low sodium), fluid management, and warning signs of decompensation is essential. **Urgent concerns include decompensated cirrhosis with evidence of ascites and early renal impairment. There is a high risk of further complications such as hepatic encephalopathy, variceal bleeding, and hepatocellular carcinoma. Prompt and aggressive management is required.** Follow-up: Recommended follow-up in 2 weeks for review of further blood tests, initiation of diuretics, and comprehensive patient education. Will schedule endoscopy for variceal screening once stabilised. Close monitoring of renal function, electrolytes, and liver function tests will continue.