Andy Goldman
Age: 40 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask from head to toe as usual;
- Ask about yellowish discoloration or eyes or skin
- Ask about itch
- Ask about right sided abdominal pain
- Ask about tiredness or fatigue
- Ask about change in colour of stool and urine
- Ask about recent travel history
- Ask about fever and unintentional weight loss
- Ask about tattoos, blood transfusions, or IV drug use (hepatitis risk factors)
- Ask about use of over the counter or herbal medications/supplements
- Explore psychosocial history – diet, weight, smoking, alcohol intake
- Ask about home situation, including duration of relationship with current partner (to assess risk of hepatitis B transmission)
- Offer a working diagnosis of fatty liver (hepatic steatosis), potentially linked to raised BMI/obesity
Example of explanation To Patient
Andy, thanks for coming in to chat about your blood test results. One of the tests we did looks at how your liver is working, and a couple of the results were slightly higher than we’d normally expect. This can sometimes be a sign that your liver is under a bit of strain.
Now, you mentioned that you don’t drink much alcohol, which is good. One possible reason for these results, especially since your weight is on the higher side, is something called ‘fatty liver’. That just means there might be a bit of fat building up in the liver.
The reason we want to take this seriously now is because if it’s left untreated for many years, it can sometimes lead to more serious liver problems later on. But the good news is that we’ve caught it early, and there’s a lot we can do to reverse or slow down any progression.
Often, the most effective way to manage this is through lifestyle changes, particularly around diet and physical activity. These changes can help reduce the fat in your liver and improve overall liver health.
Before we jump into suggestions, I’d love to hear your thoughts:
What changes do you think you could make to your current diet?
How do you feel about your current level of physical activity?
If you’re busy or don’t enjoy cooking, some patients find services like Hello Fresh or other meal prep providers useful, they offer simple, healthy meal kits that save time while supporting better eating habits.
In terms of exercise, even something as straightforward as a 30-minute daily walk can make a big difference. You might find it helpful to swap short drives for walking or use public transport to increase your daily steps. It doesn’t need to be intense; consistency is what matters most.
To be on the safe side, I’d like to do a couple more tests and arrange a scan to have a closer look at your liver. It’s nothing to panic about, but it’s worth keeping an eye on now so it doesn’t lead to problems in the future. Once we have all the results, we’ll put your numbers into a medical calculator called the NAFLD score, which estimates the risk of your fatty liver progressing to liver damage.
If your risk is high, we’ll refer you to a specialist liver team for further assessment and support.
If your risk is low, that’s great, we’ll just continue monitoring it every three years to keep things on track.
Management
- Offer further investigations- Hepatitis B & C screen, Autoimmune liver screen, AST (for NAFLD scoring), Lipid profile (cholesterol)
- Offer abdominal ultrasound to check for fatty liver or other causes
- Advice that you will calculate his risk of liver damage with a medical calculator called NALFD score
- Offer to calculate Q-risk too (for cardiovascular risk)
- If there were no blood pressure readings or BMI given, then arrange face-to-face review to examine abdomen, recheck BP, and offer weight management support
- Give lifestyle advice: Weight loss through diet/exercise, avoid processed/fatty foods, limit alcohol, even if drinking is low
- Suggest convenient healthy eating options like “HelloFresh” for those who find cooking difficult
- Safety net for signs of liver complications: jaundice, rash, abdominal pain, changes in stool or urine colour, or tremors — advise urgent medical review if any occur
- Plan a follow-up in 1 week to review investigation results and next steps
Learning point from this station:
Learning Point – NAFLD and Abnormal LFTs in Primary Care
Mildly raised liver enzymes, especially ALT and GGT, in an otherwise well adult with risk factors such as obesity or sedentary lifestyle should raise suspicion of non-alcoholic fatty liver disease (NAFLD). This is often picked up incidentally during routine blood tests.
If the patient had a recent viral illness or was on new medication, a repeat test in 1–2 weeks may help determine if it’s a transient rise.
A liver ultrasound and additional tests (e.g. Hepatitis screen, autoimmune panel, metabolic screen) may be appropriate for ongoing abnormal LFTs or when abnormal LFTs are identified for the first time without an apparent cause (this is particularly relevant in asymptomatic patients, as in the case above, where non-alcoholic fatty liver disease (NAFLD) is a possible underlying diagnosis).
Early detection of NAFLD provides a window for intervention through lifestyle change — reducing the risk of long-term progression to fibrosis or cirrhosis
Understanding LFTs: Key Points for Interpretation
- ALT and AST: These are enzymes found in liver cells (hepatocytes). A rise in ALT or AST suggests liver cell irritation or damage (e.g. in NAFLD, viral hepatitis, or drug-induced injury).
- ALP and GGT: These are interpreted together to help determine if a raised ALP is due to liver or bone origin:
- ALP is found in both the liver and bone. A raised ALP alone could indicate bone disease (e.g. vitamin D deficiency, Paget’s disease, bony metastases).
- GGT is specific to the liver. If both ALP and GGT are raised, this strongly points to a liver-related cause (e.g. biliary obstruction or fatty liver).
- An isolated raised GGT is classically linked to alcohol excess
This station reinforces the importance of interpreting LFTs in clinical context and acting early to prevent long-term liver complications.