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Assessment:
Imaging and/or labs are consistent with cirrhosis, showing a nodular liver, splenomegaly, elevated liver enzymes, low albumin, and prolonged INR. Differential diagnosis includes alcoholic liver disease, non-alcoholic fatty liver disease, chronic viral hepatitis (B/C), autoimmune hepatitis, hemochromatosis, primary biliary cholangitis, Wilson’s disease, and medication-induced liver injury.
Plan:
Further workup includes hepatitis panel, autoimmune markers, iron studies, ceruloplasmin, and alpha-1 antitrypsin levels. Management involves alcohol cessation if applicable, weight management for NAFLD, and avoiding hepatotoxic medications. Screen for complications: order an upper endoscopy (once a year) for esophageal varices, abdominal ultrasound (every 6 months) with AFP for hepatocellular carcinoma, and monitor for ascites, hepatic encephalopathy, portal hypertension, and coagulopathy. A referral to GI is placed for further evaluation and management, including liver biopsy if necessary. Regular follow-up with primary care and GI is planned, with ongoing monitoring of liver function, CBC, and INR.
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