Date:
Patient:
MRN:
Clincian: (Hepatologist, Gastroenterologist)
Reason for Visit:
Follow-up for hepatic hemangioma
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 (estrogen use, hormonal therapy)
Previous surgeries or hospitalizations
History of trauma to the liver (uncommon cause)
Family History:
Family history of hemangiomas (uncommon)
Social History:
Current and past oral contraceptive or hormonal therapy use (estrogen-containing)
Physical Exam:
Vital Signs: Normal vital signs are expected unless complications arise (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 hemangioma but may be performed to assess overall health.
Consider mentioning liver function tests (LFTs) if performed.
Alpha-fetoprotein (AFP) levels:
Elevated AFP is usually not associated with hemangioma and may suggest a different liver lesion. Consider mentioning if AFP was checked and the result.
Imaging:
Ultrasound: Often the initial imaging study to detect a liver mass.
Consider mentioning characteristic ultrasound findings of hemangioma (well-defined margins, echogenic with posterior enhancement).
CT scan or MRI: May be used for further characterization of the hemangioma, especially if atypical features are seen on ultrasound or if symptoms are present.
Consider mentioning specific imaging findings suggestive of hemangioma on CT or MRI (homogeneous enhancement on contrast).
Assessment:
Summarize the diagnosis of hepatic hemangioma based on imaging studies.
Mention the size and location of the hemangioma.
Discuss the risk of complications (bleeding, rupture) based on the size and characteristics of the hemangioma.
Plan:
Outline the management plan based on the size, characteristics, and symptoms:
Observation: For small, asymptomatic hemangiomas with characteristic imaging features, observation with serial imaging (ultrasound every 1-2 years) is often recommended.
Hormonal therapy modification: Discontinuation of estrogen-containing medications may be considered, especially if symptoms are present.
Embolization: Minimally invasive procedure to block blood flow to the hemangioma, used for symptomatic or large hemangiomas.
Surgery: Rarely performed, may be considered for very large or symptomatic hemangiomas not amenable to other treatments.
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 hemangioma 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) if applicable
Warning signs and symptoms of potential complications (acute abdominal pain, bleeding)
The benefits and risks of embolization or surgery 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.