Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of hepatic steatosis. History is significant for [metabolic syndrome/obesity/T2DM/dyslipidemia]. Patient reports [asymptomatic/vague RUQ discomfort/fatigue]. Denies history of significant alcohol consumption, viral hepatitis, or hepatotoxic medication use. Ultrasound imaging confirms Grade [1/2/3] hepatic steatosis.
Clinical Examination Findings
General: Well-appearing, non-icteric. Abdomen: Soft, non-tender, non-distended. Hepatomegaly: [Present/Absent]. Liver span: [cm]. Splenomegaly: [Present/Absent]. Stigmata of chronic liver disease: [Absent/Present, e.g., spider angiomata, palmar erythema]. BMI: [Value] kg/m².
Treatment Protocol
Plan: 1. Lifestyle modification: Weight loss goal of 7-10% of body weight. 2. Dietary: Mediterranean-style diet, restriction of refined sugars and fructose. 3. Exercise: Minimum 150 minutes of moderate-intensity aerobic activity per week. 4. Metabolic optimization: Management of glycemic control and lipid profile. 5. Follow-up: Repeat LFTs and imaging in [6-12] months.