Personal Details:
Mrs. Maria Rodriguez
Age: 58
Medical Record:
Past medical history: Type 2 Diabetes, Hypertension, Hypercholesterolemia, BMI 31
Regular medication: Metformin 500mg BD, Lisinopril 10mg OD, Atorvastatin 20mg OD.
Allergies: None known.
Notes:
Last consultation (4 months ago)
Upper right quadrant pain after eating fatty food, with mild indigestion.
No dysphagia, no change in bowel habits, no blood in stool.
BP130/80
GP requested routine bloods and liver u/s to exclude gallstones.
GP advised lifestyle changes, try Gaviscon PRN when needed
Recent lab results (3 months ago): FBC normal, platelet 340, HbA1c 51 mmol/L, LFTs normal, ALT 33, AST 21, Lipid profile raised, cholesterol/HDL ratio 6.2, Qrisk 16.7%.
Abdominal US report:
Increased echogenicity of the liver, consistent with fatty infiltration (NAFLD)
No gall bladder pathology, no splenomegaly, no KUB pathology or stones.
No reason identified for the abdominal pain.
Opening Sentence: “Doctor, I am here for my ultrasound scan result?”
Open History (to give freely): Patient is concerned and confused about the NAFLD diagnosis. She has heard of fatty liver but doesn’t understand its implications.
Cues to give:
“I try to eat healthy, but it’s hard with my busy schedule.” (If picked up, the patient will express challenges with lifestyle changes.)
ICE:
Ideas: You don’t have any idea why you have these fatty liver changes
Concerns: Worried about her long-term health and the potential for liver damage. Anxious about the unknown implications of the diagnosis.
Expectation: Wants to know what the scan shows.
When informed about the scan results, hopes for a simple treatment, perhaps a pill, to reverse the condition. Wants to know what she needs to do to prevent it from getting worse.
How to Act: Slightly confused and concerned by the diagnosis.
More History (only if asked):
· Abdominal pain and indigestion have almost completely settled and rarely need Gaviscon. You don’t have any new abdominal discomfort or pain.
· No jaundice (yellowish or greenish skin discoloration), ascites (abdominal swelling), bruises or bleeding tendencies.
· No significant fatigue.
· Not physically active. Office worker. No exercise or hobbies.
Social History:
Occupation: Office worker
Smoking: Non-smoker.
Alcohol: Occasional social drinker (1-2 units/week). Never been a heavy drinker.
Home situation: Lives with husband and adult children.
Questions to ask: “What caused this?” “Can it be cured?” “Do I need to take new medication?”
Explain the situation and manage ICE:
· Good morning, Mrs. Rodriguez. Thank you for coming in. Your ultrasound scan didn’t find any concerning reasons for your abdominal discomfort, which is reassuring. However, it indicated to some changes in your liver.
· It indicated for what we call fatty Liver Disease, or NAFLD. It means there’s an excess of fat stored in your liver cells.
· You’re right to ask if it’s serious. For many people, it’s a mild condition and doesn’t cause significant problems. However, for some, it can progress to more serious liver damage over time, like inflammation, scarring (fibrosis), and in rare cases, even cirrhosis or liver cancer.
· The good news is that it’s often reversible, especially in the early stages, and it’s usually not caused by alcohol, which is why it’s called ‘non-alcoholic.’ It’s very strongly linked to conditions like Type 2 Diabetes, high blood pressure, high cholesterol, and carrying extra weight, all of which you have. So, it’s not a surprise that we’ve found it. My goal is to explain what this means for you and what steps we can take to manage it and prevent it from getting worse.
Next Steps: Manage in primary care, referral, and further tests, etc.
· The most effective treatment for NAFLD is lifestyle modification. This means focusing on weight loss, healthy eating, and regular physical activity. Much of the advice to treat this is the same as the advice we have given to you about your diabetes. Even a modest weight loss of 5-10% of your body weight can significantly improve NAFLD. We also need to ensure your diabetes, blood pressure, and cholesterol are well-controlled, as managing these conditions will also help your liver.
· We’ll continue with your current medications for these. There isn’t a specific medication just for NAFLD.
· I can see you are already on atorvastatin, which should help to improve your cholesterol, but I wonder if the current dose is not enough, so we possibly
· We’ll monitor your liver function tests regularly, and if there are any signs of progression, we might consider further investigations or a referral to a liver specialist.
What is scenario testing? This scenario tests the GP trainee’s ability to explain and manage Non-Alcoholic Fatty Liver Disease (NAFLD) in a patient with multiple metabolic risk factors (Type 2 Diabetes, Hypertension, Hypercholesterolemia, obesity). It assesses their ability to provide clear education about NAFLD, emphasize lifestyle modifications as the primary treatment, manage patient concerns about serious liver disease, and coordinate care with other specialties (e.g., dietetics). It also tests communication skills, particularly in motivating lifestyle changes.
Important areas in data gathering:
· Patient’s understanding of NAFLD and its implications.
· Alcohol intake history (to differentiate from alcoholic liver disease).
· Dietary habits and physical activity levels.
· Control of underlying metabolic conditions (diabetes, hypertension, hypercholesterolemia).
· Symptoms of liver disease (fatigue, jaundice, ascites, encephalopathy).
· ICE (Ideas, Concerns, Expectations), especially fear of progression to serious liver disease.
Highlight the management objectives,
· Education & Explanation: Provide a clear, understandable explanation of NAFLD, its causes, and potential progression, differentiating it from alcoholic liver disease.
· Lifestyle Modification: Emphasize weight loss (even modest amounts), healthy diet, and regular exercise as the cornerstone of treatment. Offer a referral to a dietitian or weight management programs.
· Optimize Metabolic Control: Ensure optimal management of co-existing conditions like Type 2 Diabetes, hypertension, and hypercholesterolemia.
· Reassurance: Address patient’s fears about liver failure or cancer, explaining that early NAFLD is often a mild non non-serious condition.
· Depending on access and local guidance, you might consider referral or advice and guidance to a hepatologist if they would consider a fibroscan. In a different scenario, if associated with abnormal LFTS, you can consider further testing, including a blood test for a liver screen.
· Monitoring: Plan for regular monitoring of liver function tests and potentially further imaging if there are signs of progression. NICE suggest 3 yearly f/u for uncomplicated NAFLD.
· Safety Netting: Advise on symptoms that would warrant urgent medical review (e.g., jaundice, severe abdominal pain).
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