Date:
Patient:
MRN:
Clinician: (Hepatologist, Gastroenterologist)
Reason for Visit:
Follow-up for focal liver lesion(s)
(Optional) Specify reason for follow-up (incidental finding, surveillance, post-treatment)
Review of symptoms and imaging studies
History of Present Illness:
Onset and nature of any symptoms suggestive of liver disease (abdominal pain, jaundice, fatigue, nausea).
Details of the initial detection of the focal liver lesion(s) (imaging modality, size, location).
Previous evaluations or interventions related to the lesion(s) (biopsy, ablation, etc.).
Past Medical History:
Underlying liver disease (hepatitis B, C, cirrhosis)
Other medical conditions that may affect the liver (metabolic disorders, autoimmune diseases)
History of medications or toxins known to cause liver damage
Family History:
Family history of liver disease or specific conditions causing focal lesions (e.g., hemochromatosis)
Social History:
Alcohol consumption
History of recreational drug use
Medications:
Current medications, including any potentially hepatotoxic medications
Physical Exam:
Vital Signs: Temperature, presence of fever suggestive of infection.
Jaundice (yellowing of the skin and sclerae)
Abdominal: Palpation for hepatomegaly (enlarged liver) or tenderness
Labs:
Liver function tests (LFTs): Evaluate for underlying liver dysfunction.
Alpha-fetoprotein (AFP): Tumor marker sometimes elevated in certain liver cancers.
Consider mentioning other labs ordered based on suspicion:
Viral hepatitis serologies (HBsAg, anti-HCV)
Iron studies (ferritin, transferrin saturation) – for hemochromatosis workup
Imaging:
Previous imaging studies: Briefly describe the findings of the imaging study that identified the focal liver lesion(s) (ultrasound, CT scan, MRI).
Include details like size, location, characteristics (solid, cystic, vascular).
Follow-up imaging (if performed): Describe the findings of any recent imaging studies used to monitor the lesion(s) for changes in size or appearance.
Assessment:
Summarize the current status of the focal liver lesion(s) based on history, physical exam, labs, and imaging.
Discuss the differential diagnosis based on the characteristics of the lesion(s) (benign vs. malignant, specific types of tumors, vascular lesions, etc.).
Consider the risk factors for malignancy based on the patient’s history.
Plan:
Outline the next steps based on the assessment:
Surveillance: Continued monitoring of the lesion(s) with periodic imaging (ultrasound, CT scan) at designated intervals.
Liver biopsy: Minimally invasive procedure to obtain tissue sample for definitive diagnosis, especially if malignancy is suspected.
Further workup: Additional tests depending on the suspected diagnosis (e.g., viral serologies for infectious causes).
Referral: Consultation with a specialist (surgical oncologist, transplant hepatologist) for further management if indicated.
Education:
Document any education provided to the patient regarding:
The nature of focal liver lesions and the differential diagnosis
The importance of adhering to the follow-up plan
The potential risks and benefits of further investigations or interventions
Notes:
Include any additional relevant information not covered above, such as the patient’s anxiety level and any specific concerns they may have.
Consider mentioning the importance of maintaining a healthy lifestyle to promote liver health.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.