Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Fatigue
Weakness
Nausea or vomiting
Loss of appetite
Abdominal pain (right upper quadrant)
Dark urine
Jaundice (yellowing of skin and whites of the eyes)
History of Present Illness:
Onset, duration, and severity of symptoms.
Any recent changes in symptoms or new exposures.
Occupational History:
Current and past occupations (focusing on potential exposures to hepatotoxins
liver toxins).
Specific details of potential exposures (e.g., type of chemicals, duration
of exposure, use of personal protective equipment (PPE)).
Any history of work-related injuries or illnesses.
Past Medical History:
Underlying medical conditions (e.g., diabetes, hepatitis B or C).
Prior surgeries (abdominal surgeries may increase risk of complications
from occupational liver injury).
Alcohol consumption (can worsen liver damage).
Social History:
Tobacco use (can increase risk of liver disease).
Use of recreational drugs or over-the-counter medications (some
medications can cause liver damage).
Family History:
Family history of liver disease.
Physical Exam:
General examination: Assess for signs of liver disease (e.g., jaundice,
ascites – fluid buildup in the abdomen, spider angiomas – small red
vascular lesions on skin).
Abdominal examination: Palpate for liver enlargement or tenderness.
Laboratory Tests:
Liver function tests (LFTs):
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
Alkaline phosphatase (ALP)
Bilirubin (total and direct)
Albumin
Complete blood count (CBC): May show anemia if liver disease is severe.
Coagulation studies (PT/INR): May be abnormal if liver function is
impaired.
Viral serologies (hepatitis B and C): To rule out other causes of liver
disease.
Imaging Studies:
(May be used depending on clinical presentation)
Ultrasound of the liver: To assess liver size and structure, identify
any abnormalities (e.g., fatty infiltration, fibrosis).
Abdominal CT scan: May be used in some cases for a more detailed
evaluation.
Assessment:
Suspected occupational liver disease: Based on occupational history
of exposure to hepatotoxins, clinical presentation (symptoms suggestive of
liver injury), and abnormal liver function tests.
Specific cause of liver injury: May require further investigation
depending on the suspected toxin and clinical picture.
Severity of liver injury: Based on laboratory tests, imaging findings, and
clinical presentation.
Differential Diagnoses:
Consider other causes of liver disease:
Viral hepatitis (hepatitis B, C)
Alcoholic liver disease
Autoimmune hepatitis
Nonalcoholic fatty liver disease (NAFLD)
Drug-induced liver injury (DILI) from medications other than
occupational exposures
Plan:
Identification and elimination of the offending agent:
This is the
cornerstone of preventing further liver damage. May involve workplace
modifications or changes in job duties to minimize exposure.
Supportive care: Focuses on managing symptoms and preventing
complications
of liver disease (e.g., nutritional support, medications to control
symptoms like nausea).
Liver specialist referral: For complex cases or severe liver injury.
Workplace surveillance: Continued monitoring of liver function tests
to track improvement and detect any future problems.
Patient education: Educate the patient about occupational liver disease,
the importance of avoiding further exposures, and healthy lifestyle choices
to support liver health.
Prognosis:
Prognosis depends on the severity of liver injury, the specific toxin
involved, and the patient’s ability to avoid further exposures. Early
diagnosis and removal from the offending agent are crucial for a good prognosis