Hepatology Inpatient Consultation Note

Date/Time of Service: [Date and time]
Consulting Service: Hepatology
Consulting Clinician: [Name, credentials]
Requesting Service: [Service]
Requesting Clinician: [Name, credentials]
Location: [Hospital, unit/bed]
History obtained from: [patient / caregiver / chart / interpreter / bedside team] (Note any reliability limitations such as encephalopathy, intubation, sedation, language barrier, or incomplete records.)

Reason for Consult

[Consult question] (Use verbatim phrasing if available. If the question required clarification, document that clarification was obtained and from whom.)
Urgency: [routine / urgent / stat]
Scope: [one-time recommendations / daily follow-up / procedure-only]

Executive Summary and Day-1 Recommendations

[Synthesis paragraph] (3–5 sentences stating working diagnosis with severity framing—compensated vs decompensated cirrhosis, acute liver injury, concern for ACLF—with 1–3 key supporting data points and immediate risks such as bleeding, infection, AKI/HRS, or airway concerns.)

• [Order/Start/Hold/Trend/Consult: Highest-priority action] (Be specific and directly orderable; include dose/route when pertinent.)
• [Order/Start/Hold/Trend/Consult: Next priority action]
• [Procedure recommendation and timing if applicable]
• [Contingency plan if clinical status changes] (Define triggers and actions.)

Communication: Recommendations communicated to [recipient] via [phone / in-person / secure message] at [time].

History of Present Illness

[Narrative HPI] (Include chief concern in patient's words when obtainable; admission diagnosis and timeline from onset to current hospital day; targeted liver symptom review including confusion/sleep reversal, GI bleeding symptoms, abdominal distension, fevers, pruritus, RUQ pain. If cirrhosis is known or suspected, include etiology, prior decompensations, baseline MELD-Na if known, and transplant status.)

Decompensation Trigger Assessment

(Include when cirrhosis complications, ACLF, hepatic encephalopathy, AKI, or acute jaundice are present. Document pertinent positives and negatives.)

• Infection: [Fever, leukocytosis, culture status, SBP evaluation]
• GI bleeding: [Melena/hematemesis, hemoglobin trend, hemodynamics]
• Volume/renal: [Diarrhea, intake, diuretic changes, nephrotoxin exposure]
• Bowel regimen: [Lactulose adherence, stool frequency]
• Sedative burden: [Benzodiazepines, opioids, gabapentinoids]
• Alcohol: [Quantity, last use, withdrawal risk]
• Thrombosis: [Portal vein thrombosis risk, Doppler status]
• Adherence: [Sodium intake, medication access, follow-up barriers]

External Records Reviewed

(Include only if outside records were reviewed. Omit section entirely if not applicable.)

• Sources reviewed: [Facility names with document types and dates]
• Key hepatology timeline: [First cirrhosis diagnosis, etiology workup, prior decompensations with dates, TIPS history, HCC history, transplant evaluation status]
• Discrepancies or uncertainties: [Note any conflicts with current presentation]

Medications

Reconciliation source: [patient / caregiver / pharmacy fill history / outside records] (Note reliability and any unconfirmed items.)

• Home regimen: [Liver-relevant medications with doses—lactulose/rifaximin with adherence, diuretics, beta-blockers, anticoagulants]
• Inpatient high-risk medications: [Sedatives/opioids, NSAIDs, ACEi/ARBs, nephrotoxins, hepatotoxins]
• Hepatology recommendations: [Continue/hold/start with rationale; note hepatic dosing adjustments]

Allergies

[Allergen]: [Reaction type and severity] (Distinguish true allergy vs intolerance when possible.)

Physical Examination

(Document targeted exam elements relevant to hepatology assessment. Note limitations if exam was restricted.)

• General: [Appearance, distress, cachexia/sarcopenia, jaundice]
• Vital signs: [Values with context]
• Skin/Eyes: [Scleral icterus, spider angiomata, bruising]
• Abdomen: [Distension, tenderness, shifting dullness, surgical scars]
• Volume status: [Edema, JVP if assessed]
• Neurologic: [Orientation, asterixis present/absent, West Haven grade if encephalopathy suspected]
• Bleeding: [Hematemesis/melena, oozing, mucosal bleeding] (Include if relevant.)

Objective Data

Laboratory Studies

(Include collection date/time. Characterize LFT pattern when acute injury present.)

• CBC: [Values and trend]
• CMP: [Sodium, creatinine, bilirubin, albumin with trends]
• LFTs: [AST, ALT, ALP, total/direct bilirubin; note hepatocellular vs cholestatic vs mixed pattern]
• Coagulation: [INR/PT, fibrinogen if obtained]
• Targeted studies: [Viral serologies, autoimmune markers, acetaminophen level, other workup as obtained]
• MELD-Na: [Score] (Cr [value], Bili [value], INR [value], Na [value]; calculated [date])
• Child-Pugh: [Class and score] (Include when procedures are being considered.)

Microbiology and Infectious Workup

(Include when decompensation, ACLF, or infection concern exists.)

• Blood cultures: [Collection date/time and status]
• Urine: [UA/UCx status]
• Chest imaging: [Findings relevant to infection]
• Ascitic fluid: [PMN count, SAAG, total protein, culture method and status]

Imaging

(Summarize relevant imaging with dates. Specify report review vs personal image review.)

• Abdominal ultrasound: [Date, liver echotexture, Doppler/portal flow, ascites]
• CT/MRI abdomen: [Date, cirrhosis morphology, biliary findings, masses/HCC status]

Procedures

(Include procedures relevant to the consultation.)

• Paracentesis: [Date, volume, PMN count, SAAG, total protein, culture; note if diagnostic vs therapeutic, albumin given]
• EGD: [Date, varices/PHG findings, interventions performed]
• TIPS: [Date, indication, gradient, patency] (If applicable.)

Assessment and Plan

(List problems in order of decreasing severity. For each problem include brief assessment with 2–4 supporting data points, followed by actionable plan.)

[Problem 1: Diagnosis or syndrome]

[Assessment with key supporting data and differential if uncertain]

• [Diagnostics]
• [Therapeutics with specific doses/routes]
• [Monitoring parameters and targets]
• [Contingency actions and triggers]

[Problem 2: Diagnosis or syndrome]

[Assessment]

• [Plan items]

(Continue with additional problems as applicable. Common hepatology problems: cirrhosis staging; ascites/SBP; AKI/HRS; hepatic encephalopathy with bowel regimen and airway precautions; variceal bleeding; acute liver injury/DILI; alcohol-associated liver disease; coagulation/VTE prophylaxis; HCC surveillance; transplant candidacy; nutrition/sarcopenia.)

Disposition and Follow-up

• Hepatology follow-up: [daily rounding / intermittent follow-up / sign-off after recommendations] (Specify re-consult triggers.)
• Outpatient needs: [Clinic follow-up timeframe, pending studies, surveillance scheduling]
• Patient education: [Key points reviewed—lactulose goals, sodium restriction, return precautions]