Date:
Patient:
MRN:
Clincian: (Hepatologist, Gastroenterologist)
Reason for Visit:
Follow-up for hepatic adenoma
Review of imaging studies (ultrasound, CT scan, MRI)
Assessment for symptoms and complications
Discussion of management plan
History of Present Illness:
Briefly describe the patient’s current status:
Presence or absence of abdominal pain, discomfort, or fullness
Any new or worsening symptoms since last visit
Changes in appetite or weight
Past Medical History:
Underlying medical conditions (oral contraceptive use, glycogen storage diseases)
Previous surgeries or hospitalizations
History of heavy alcohol use (risk factor for hepatocellular carcinoma)
Family History:
Family history of liver diseases (may suggest increased risk for certain types of adenoma)
Social History:
Current and past oral contraceptive use (estrogen-containing)
Alcohol and tobacco use
Physical Exam:
Vital Signs: Normal vital signs are expected unless complications arise (bleeding).
Abdominal exam:
Normal exam findings are common.
Consider mentioning palpable right upper quadrant mass if present.
Labs:
Routine laboratory tests are not diagnostic for hepatic adenoma but may be performed to assess overall liver function.
Consider mentioning liver function tests (LFTs) if performed.
Alpha-fetoprotein (AFP) levels:
Elevated AFP may suggest a more concerning liver lesion (hepatocellular carcinoma) and needs further workup.
Imaging:
Ultrasound: Often the initial imaging study to detect a liver mass.
CT scan or MRI: May be used for further characterization of the adenoma and to differentiate it from other liver lesions.
Consider mentioning specific imaging findings suggestive of adenoma (e.g., well-defined margins, homogenous enhancement).
Assessment:
Summarize the diagnosis of hepatic adenoma based on imaging studies and consider mentioning the specific adenoma subtype if known (e.g., inflammatory adenoma, focal nodular hyperplasia).
Discuss the risk of complications (bleeding, rupture) based on the size and location of the adenoma.
Plan:
Outline the management plan based on the size, characteristics, and risk of complications:
Observation: For small, asymptomatic adenomas with characteristic imaging features, observation with serial imaging (ultrasound every 6 months for 2 years, then annually) is often recommended.
Oral contraceptive discontinuation: For women taking oral contraceptives, discontinuation may be advised to reduce the risk of adenoma growth.
Surgical resection: May be considered for large adenomas (>5cm), symptomatic adenomas, or those with concerning features on imaging.
Consider mentioning the need for ongoing monitoring with imaging studies at specified intervals.
Education:
Document any education provided to the patient regarding:
The nature of hepatic adenoma and its potential complications
The importance of adhering to the recommended follow-up plan with imaging studies
Lifestyle modifications to reduce the risk of complications (healthy diet, weight management)
Warning signs and symptoms of potential complications (acute abdominal pain, bleeding)
The benefits and risks of surgical resection if applicable
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about follow-up imaging, potential complications, or the need for surgery.
Address the potential anxiety associated with a liver mass and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a hepatologist or gastroenterologist for diagnosis, treatment recommendations, and prognosis.