Date:
Patient:
MRN:
Clinician: (Hepatologist, Gastroenterologist)
Reason for Visit:
Follow-up for FNH
(Optional) Specify reason for follow-up (incidental finding, surveillance, post-treatment)
Review of symptoms and imaging studies
History of Present Illness:
Briefly describe any present symptoms suggestive of liver disease (abdominal pain, jaundice, fatigue, nausea).
Details of the initial detection of the FNH (imaging modality, size, location).
Previous evaluations or interventions related to the FNH (biopsy, if performed).
Past Medical History:
Underlying medical conditions (not typically associated with FNH)
History of medications or toxins known to cause liver damage (uncommon in FNH)
Family History:
Family history of liver disease (not typically relevant for FNH)
Social History:
Alcohol consumption (not typically a risk factor for FNH)
History of recreational drug use (not typically a risk factor for FNH)
Medications:
Current medications (not typically relevant for FNH management)
Physical Exam:
Vital Signs: Temperature, presence of fever suggestive of unrelated infection.
Jaundice (usually absent in FNH)
Abdominal: Palpation for hepatomegaly (enlarged liver) or tenderness (unusual in FNH)
Labs:
Liver function tests (LFTs): May be normal or mildly abnormal in some cases of FNH.
Alpha-fetoprotein (AFP): Usually within normal limits in FNH (important to rule out other liver tumors).
Consider mentioning other labs ordered to rule out other conditions:
Viral hepatitis serologies (HBsAg, anti-HCV)
Imaging:
Previous imaging studies: Briefly describe the findings of the imaging study that identified the FNH (ultrasound, CT scan, MRI).
Include details like size, location, characteristic features of FNH on imaging (central scar, radiating vessels).
Follow-up imaging (if performed): Describe the findings of any recent imaging studies used to monitor the lesion for changes in size or appearance.
Assessment:
Confirm the diagnosis of FNH based on characteristic imaging findings and the absence of risk factors for other liver tumors.
Evaluate the need for further workup to rule out other etiologies if clinical suspicion is high.
Assess the size and stability of the FNH on follow-up imaging.
Plan:
Outline the next steps based on the assessment:
Surveillance: Continued monitoring of the FNH with periodic imaging (ultrasound) at designated intervals (usually safe for stable lesions).
Consider referral to a liver specialist: If the FNH is large, rapidly growing, or causes concerning symptoms.
Reassurance: Reassure the patient if the FNH is small and stable, and unlikely to cause any problems.
Education:
Document any education provided to the patient regarding:
The nature of FNH and its benign characteristics
The importance of adhering to the follow-up plan
The low risk of complications associated with FNH
Notes:
Include any additional relevant information not covered above, such as the patient’s anxiety level and any specific concerns they may have.
Briefly discuss healthy lifestyle habits that promote overall health but are not directly related to FNH prevention.
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.