Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
(May be asymptomatic or present with) Fatigue, right upper quadrant
abdominal discomfort, weight loss (unintentional).
History of Present Illness:
Duration and severity of any symptoms.
Risk factors for NAFLD (e.g., obesity, type 2 diabetes, metabolic syndrome, family history).
Alcohol consumption habits (important to exclude significant alcohol intake).
Medications or supplements currently used.
Past Medical History:
Underlying medical conditions (e.g., diabetes, hypertension, hyperlipidemia).
Prior surgeries (abdominal surgeries may increase risk of NAFLD).
Social History:
Diet (high in saturated fat, sugar, refined carbohydrates)
Physical activity level
Family History:
First-degree relative with NAFLD, diabetes, or other metabolic disorders.
Physical Exam:
General examination: Assess for body mass index (BMI), signs of chronic liver disease (jaundice, spider angiomas, ascites).
Abdominal examination: Palpate for hepatomegaly (enlarged liver) and liver tenderness.
Laboratory Tests:
Liver function tests: May show elevated liver enzymes (alanine aminotransferase (ALT), aspartate aminotransferase (AST)) in some cases.
Complete blood count (CBC): May be normal or show mild abnormalities (e.g., iron deficiency anemia).
Fasting blood sugar or HbA1c: To assess for diabetes.
Lipid panel: To evaluate cholesterol levels and risk for cardiovascular disease.
Fibrosis markers (optional): Tests like FibroTest or FibroScan may be used to assess the degree of liver fibrosis (scarring), but are not routinely done in all cases.
Imaging Studies:
Ultrasound: Initial imaging study to assess for liver fat content and exclude other liver diseases.
MRI or CT scan (less preferred): May be used in some cases for better visualization or to rule out other conditions.
Assessment:
Non-alcoholic fatty liver disease (NAFLD): Based on clinical presentation (risk factors, symptoms), laboratory findings (possibly elevated liver enzymes), and imaging studies demonstrating liver fat.
Grade of steatosis (fat accumulation): Can be estimated by imaging studies or liver biopsy (not routinely performed).
Presence of non-alcoholic steatohepatitis (NASH): NASH is a more advanced form of NAFLD with inflammation and liver cell injury. Distinguishing NAFLD from NASH is often challenging and may require additional testing or liver biopsy.
Stage of fibrosis (if assessed): Fibrosis is a key factor in the progression of NAFLD to cirrhosis.
Differential Diagnoses:
Consider other causes of elevated liver enzymes or fatty liver:
Alcoholic liver disease
Viral hepatitis (hepatitis B, C)
Autoimmune hepatitis
Drug-induced liver injury
Genetic liver diseases
Plan:
The treatment plan aims to address the underlying cause (e.g., weight loss, diet modification, exercise) and prevent progression to NASH and cirrhosis. Possible elements include:
Lifestyle modifications: Weight loss through a healthy diet and increased physical activity are the cornerstones of treatment.
Dietary changes: Reduce intake of saturated fat, sugar, and refined carbohydrates. Increase intake of fruits, vegetables, and whole grains.
Medications: Currently, there are no specific medications approved for NAFLD, but medications for diabetes or cholesterol may be used to address associated conditions.
Monitoring: Regular follow-up with laboratory tests and imaging may be needed to monitor liver function and disease progression.
Referral: Consider referral to a hepatologist (liver specialist)
for complex cases or if NASH is suspected.