Date:
Patient:
MRN:
Clincian: (Hepatologist, Gastroenterologist)
Reason for Visit:
Follow-up for hepatic cyst
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 (polycystic liver disease, Caroli disease)
Previous surgeries or hospitalizations
History of trauma to the liver
Family History:
Family history of polycystic liver disease (suggests increased risk)
Social History:
Not typically relevant unless affecting overall health.
Physical Exam:
Vital Signs: Normal vital signs are expected unless complications arise (infection, bleeding).
Abdominal exam:
Normal exam findings are common.
Consider mentioning a palpable right upper quadrant mass if present.
Labs:
Routine laboratory tests are not diagnostic for hepatic cyst but may be performed to assess overall health.
Consider mentioning liver function tests (LFTs) if performed.
Consider mentioning a complete blood count (CBC) if infection is suspected (elevated white blood cells).
Imaging:
Ultrasound: Often the initial imaging study to detect a liver cyst.
CT scan or MRI: May be used for further characterization of the cyst, especially if complex or atypical features are seen on ultrasound.
Consider mentioning specific imaging findings suggestive of a benign cyst (e.g., well-defined margins, anechoic fluid on ultrasound).
Assessment:
Summarize the diagnosis of hepatic cyst based on imaging studies.
Discuss the size, location, and characteristics of the cyst.
Differentiate between a simple cyst and a more complex cyst (e.g., with internal septations) based on imaging findings.
Plan:
Outline the management plan based on the size, characteristics, and symptoms:
Observation: For small, asymptomatic cysts with characteristic imaging features, observation with serial imaging (ultrasound every 1-2 years) is often recommended.
Aspiration: Percutaneous needle aspiration to drain the cyst fluid may be performed for symptomatic cysts or those with atypical features on imaging.
Laparoscopic or open surgical intervention: May be considered for very large cysts causing significant symptoms or complications (infection, rupture).
Consider mentioning the need for ongoing monitoring with imaging studies at specified intervals if observation is chosen.
Education:
Document any education provided to the patient regarding:
The nature of hepatic cysts and their potential complications
The importance of adhering to the recommended follow-up plan with imaging studies
Warning signs and symptoms of potential complications (acute abdominal pain, fever)
The benefits and risks of aspiration or surgical intervention 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 procedures.
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.