Abnormal Liver Enzymes Workup Note

Date/Time: [Date and time of note]

Patient: [Patient name / MRN / DOB]

Note Type: [Consult / Progress] [Service or clinic name]

Consult Question: [Specific clinical question being addressed] (Only include if this is a consult)

Data Sources: [Patient / family / outside records / pharmacy data / prior labs and imaging / interpreter if used]

Chief Concern

[Reason for evaluation of abnormal liver chemistries] (One line; if consult, include why now such as screening labs, pre-op evaluation, new symptoms, or medication change)

Focused Clinical Summary

[Two to four sentences summarizing: most abnormal recent AST, ALT, ALP, total and direct bilirubin with dates and multiples of ULN; overall trend direction; pattern classification (hepatocellular / cholestatic / mixed / isolated hyperbilirubinemia); synthetic function status (INR, albumin); presence or absence of red flags such as jaundice, confusion, bleeding, or fever with RUQ pain]

History of Present Illness

[Discovery context and timeline including how and when the abnormality was found, prior baseline values if known, recent intercurrent illness or triggers, and chronicity (acute vs chronic)]

Pattern Classification: [Hepatocellular / cholestatic / mixed / isolated hyperbilirubinemia], [severity using multiples of ULN]. [R-ratio calculation with inputs and date if used: R = (ALT/ULN) ÷ (ALP/ULN); R >5 hepatocellular, R <2 cholestatic, R 2–5 mixed]. [Bilirubin fractionation status if elevated: direct vs indirect predominant / not yet obtained]

Symptom Inventory: [Jaundice, dark urine, pale stools, pruritus, RUQ or epigastric pain, fever, nausea, anorexia, weight loss, confusion or somnolence, bleeding or bruising] (Document pertinent positives and negatives)

Exposure Review (Document thoroughly; if any domain not assessed, state why and plan to obtain)

• Medications and Supplements: [List all prescription and OTC medications; new medications in past 3–6 months; dose changes; recent short courses; total daily acetaminophen dose; all supplements including bodybuilding, weight-loss, detox, herbal, and traditional products with name, dose, start/stop dates] (If list incomplete, document efforts to obtain)
• Alcohol: [Average drinks per week; daily vs binge pattern; date of last drink; prior withdrawal or pancreatitis; prior treatment; validated screen result if obtained]
• Metabolic Risk Factors: [Weight and BMI trend; diabetes or prediabetes; dyslipidemia; hypertension; OSA; diet and activity pattern; prior imaging showing steatosis]
• Viral and Blood-borne Risk: [Injection or intranasal drug use ever; shared equipment; tattoos or piercings; transfusion or transplant history; dialysis; incarceration; birthplace or travel from high-prevalence regions; household contacts; relevant sexual exposures; needlestick; travel with food or water risk if acute hepatitis suspected]
• Autoimmune and Cholestatic Clues: [Personal autoimmune disease; sicca symptoms; history of IBD; pruritus disproportionate to jaundice]
• Family History: [Hemochromatosis; Wilson disease; alpha-1 antitrypsin deficiency; autoimmune liver disease; cirrhosis; early HCC]

Relevant Background

[Prior liver disease or biopsy; prior hepatitis diagnosis or treatment; comorbidities affecting interpretation such as CHF, CKD, thyroid disease, celiac; prior biliary surgery; relevant allergies and drug reaction history] (Omit section if no relevant background)

Focused Physical Exam

Vitals: [Relevant vitals if applicable]

[General appearance; eyes and skin for scleral icterus, jaundice, excoriations; abdomen for RUQ tenderness, hepatomegaly, splenomegaly, ascites; stigmata of chronic liver disease such as spider angiomas or palmar erythema; neurologic orientation and asterixis if concern; volume status and edema] (Document only what was assessed; if exam limited, document limitation)

Objective Data

Liver Chemistry Trend

(Present by date; include multiples of ULN; identify peak values and trajectory)

• [Date]: AST [value] ([x ULN]); ALT [value] ([x ULN]); ALP [value] ([x ULN]); T. bili [value]; D. bili [value if available]; INR [value]; Albumin [value]; Platelets [value]
• [Additional dated entries as available]
• Trend: [Improving / stable / worsening]; Peak values: [Specify tests and dates]

Additional Labs

[CBC, BMP, lipids, A1c, pregnancy test, GGT, CK as relevant] (Include only tests that were obtained)

Completed Etiologic Evaluation

• Viral hepatitis: [HBsAg, anti-HBs, anti-HBc, HCV Ab with reflex RNA, HAV IgM; results with dates and interpretation]
• Autoimmune markers: [ANA, ASMA, anti-LKM, IgG level; results with dates]
• Iron studies: [Ferritin, transferrin saturation; results with dates]
• Wilson disease screen: [Ceruloplasmin; results with dates] (Include if obtained)
• Alpha-1 antitrypsin: [Level and phenotype; results with dates] (Include if obtained)
• Other tests: [EBV, CMV, IgG4, celiac serologies as indicated]
• Pending or gaps: [List missing or pending studies]

Imaging

• [Ultrasound (date): steatosis, biliary dilation, masses, Doppler findings]
• [MRCP, CT, or MRI (date): key findings] (Include if obtained)
• [Elastography (date): kPa value and interpretation] (Include if obtained)

Assessment

[Diagnostic summary: 1–3 sentences covering pattern, severity, chronicity, synthetic function status, top suspected etiologies with supporting features, and key uncertainties]

Problem List

• Abnormal liver chemistries: [Pattern; severity; trajectory]
• [Suspected or confirmed DILI with suspected agent and timing] (Include if applicable)
• [Alcohol-related risk or disorder] (Include if applicable)
• [MASLD (formerly NAFLD) with risk factors] (Include if applicable)
• [Fibrosis staging or portal hypertension evaluation needed] (Include if applicable)
• [Other relevant diagnoses or contributors]

Plan

Abnormal Liver Chemistries

Interpretation: [Restate pattern and determination method including R-ratio and bilirubin fractionation if relevant; synthetic function status; whether portal hypertension is suspected]

Confirmatory Steps: [Repeat liver chemistries to confirm and establish trajectory with timing; GGT to confirm hepatic source of isolated ALP elevation; CK if extrahepatic source suspected] (Include only steps that are indicated)

Serologic Evaluation: (For each test, indicate: ordered today / already done / pending / not indicated)

• Hepatocellular pattern: [HAV IgM if acute; HBsAg, anti-HBc, anti-HBs; HCV Ab with reflex RNA; iron studies; autoimmune panel (ANA, ASMA, anti-LKM, IgG); Wilson screen if age <40; alpha-1 antitrypsin]
• Cholestatic pattern: [RUQ ultrasound first; AMA for PBC; MRCP if persistent cholestasis; PSC evaluation if IBD or characteristic imaging; IgG4 if suspicion]
• Mixed pattern: [Combined hepatocellular and cholestatic evaluation; emphasize DILI and biliary obstruction exclusion]
• Isolated hyperbilirubinemia: [Confirm fractionation; if indirect: hemolysis workup (retic, LDH, haptoglobin), hereditary syndromes; if direct: evaluate as cholestatic or hepatocellular]

Imaging Strategy: [Abdominal ultrasound as first-line with Doppler if vascular or portal hypertension concern; MRCP if cholestasis persists or PSC suspected; CT or MRI if mass suspected or unexplained cholestasis] (Document clinical question for each study ordered)

Fibrosis Staging: [FIB-4 calculated value and interpretation (low / indeterminate / high risk); if indeterminate or high, plan for elastography and hepatology referral; if cirrhosis suspected, outline surveillance plan or defer to hepatology] (Include if MASLD, alcohol-related disease, or chronic abnormalities)

Therapeutic Actions:

• [Medications and supplements held or stopped with plan to avoid re-challenge without specialist guidance]
• [Alcohol counseling and cessation support with referrals]
• [Metabolic risk modification: weight management, diabetes, lipid, and BP optimization]
• [Vaccination review: HAV and HBV immunity]

[Secondary Problem]

[Key details, rationale, counseling, actions taken, follow-up steps] (Repeat section for each secondary problem such as suspected DILI, alcohol use disorder, or MASLD)

Monitoring and Return Precautions

Planned Monitoring: Repeat AST, ALT, ALP, bilirubin, INR, albumin, platelets on [date or interval]. Next visit [date or interval], [in-person / telehealth].

Urgent Escalation Thresholds (ED evaluation):

• New or worsening jaundice
• Confusion, somnolence, or asterixis concerning for encephalopathy
• Severe or persistent vomiting or inability to maintain hydration
• GI bleeding or significant bruising
• Fever with RUQ pain or concern for ascending cholangitis
• Evidence of synthetic impairment (rising INR or INR ≥1.5 without anticoagulation)
• Rapid enzyme rise, very high aminotransferases (AST or ALT >1000), or Hy's Law pattern (ALT or AST ≥3× ULN with total bilirubin ≥2× ULN)
• Suspected biliary obstruction with systemic illness
• High-risk abnormalities with unreliable follow-up

Specialist Referral Thresholds:

• Persistent unexplained abnormalities after initial evaluation
• Intermediate or high fibrosis risk or signs of advanced liver disease
• Cholestasis with negative initial evaluation or concern for PBC or PSC
• Suspected severe DILI or complex polypharmacy