General Practice Clinic: Case Analysis of a "Three Highs" Patient with Coexisting Fatty Liver Disease

LI Jie¹, YANG Xinhui¹, CAO Li², ZHANG Jing³, JIANG Yue⁴

¹Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
²Baizhifang Community Health Service Center, Xicheng District, Beijing 100054, China
³Department of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing 100069, China
⁴Department of General Practice, the First Hospital of Tsinghua University, Beijing 100016, China

Corresponding authors: CAO Li, Associate Chief Physician; E-mail: caoli1983@163.com
JIANG Yue, Chief Physician; E-mail: redtealook9@sina.com
LI Jie and YANG Xinhui are co-first authors

Abstract

Background: Hypertension, diabetes mellitus, and dyslipidemia (the "three highs") frequently coexist with metabolic dysfunction-associated steatotic liver disease (MASLD). These conditions interact synergistically, significantly elevating the risk of adverse cardiovascular and hepatic outcomes. Currently, standardized diagnostic and treatment pathways for such comorbid patients managed by general practitioners in primary care settings remain under exploration.

Objective: Through a typical case report, this paper aims to explore the diagnostic thinking and practical workflow of general practitioners in managing patients with "three highs" coexisting with MASLD.

Methods: We report the general practice process of screening, identification, risk assessment, two-way referral, and comprehensive management in a patient with "three highs" and MASLD, demonstrating an individualized comprehensive management plan and general practice diagnostic pathway.

Results: Following eight months of full-course, comprehensive management led primarily by general practitioners, the patient achieved target blood pressure and glucose levels, reduced low-density lipoprotein cholesterol, experienced weight loss and decreased waist circumference, showed significant improvement in hepatic steatosis and fibrosis, and demonstrated markedly improved medication adherence and self-management capabilities.

Conclusion: General practitioner-based comprehensive management of patients with "three highs" and fatty liver disease can significantly improve metabolic indicators and liver status, reflecting the central role of general practice in managing multiple chronic conditions and providing practical reference for optimizing standardized management pathways for such patients at the primary care level.

Keywords: Three highs; Fatty liver; Hypertension; Diabetes mellitus; Dyslipidemias; General practice; Case report

Fatty liver disease (FLD) encompasses a heterogeneous group of conditions resulting from complex interactions among susceptibility genes, epigenetics, diet, and lifestyle factors. Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly known as non-alcoholic fatty liver disease (NAFLD), represents the most common form of FLD. In China, the prevalence of MAFLD is approximately 29.6%, increasing with the number of metabolic syndrome components, BMI, and the severity of glucose metabolism abnormalities. Among hypertensive patients, the prevalence of NAFLD reaches 39.3%, while in type 2 diabetes patients it is 51.8%, and among those with dyslipidemia, it climbs to 69.2%. In terms of natural disease history, MAFLD and the "three highs" (hypertension, diabetes, and dyslipidemia) influence each other in a vicious cycle, collectively promoting increased risks of atherosclerotic cardiovascular disease, chronic kidney disease, hepatocellular carcinoma, and extrahepatic malignancies.

Due to factors such as the large patient population, insufficient diagnostic tools, and lack of effective pharmacological treatments, primary care general practitioners face challenges in early identification of high-risk individuals, timely diagnosis, and comprehensive assessment. Guidelines recommend implementing evidence-based referral systems, stratified management, and scientific interventions to improve patient prognosis. As the "frontline" of disease management, community health centers possess convenient conditions for screening and identifying risk factors. However, China has yet to establish a mature community-based management and two-way referral model for MAFLD, and standardized chronic disease management for FLD remains exploratory.

This article reports a primary care patient with "three highs" coexisting with FLD, demonstrating the clinical practice process of screening using the Fibrosis-4 (FIB-4) index combined with liver elastography, risk assessment, two-way referral, and comprehensive management. The aim is to enhance primary care physicians' understanding of this disease, strengthen capabilities in disease screening, risk assessment, two-way referral, and comprehensive management, and provide reference for optimizing general practice diagnostic pathways and community management models for patients with "three highs" and fatty liver disease.

1.1.1 Subjective Data (S)

The patient is a 69-year-old male with junior high school education, retired worker, and registered patient with "three highs." He presented with "intermittent abnormal liver function for one year" and visited the community clinic in April 2024. Considering him a high-risk individual for FLD, the physician ordered complete blood count, liver function, renal function, and other tests. The calculated FIB-4 index was 7.40, indicating high risk for advanced liver fibrosis, prompting further liver elastography examination. Since onset, the patient denied nausea, vomiting, anorexia, diarrhea, abdominal pain, dizziness, headache, blurred vision, palpitations, heat intolerance, diaphoresis, limb pain or numbness, or fine hand tremors. He reported adequate diet and sleep, normal bowel movements and urination, with no significant weight changes.

Past Medical History: Hypertension for 15 years, with maximum blood pressure reaching 160/95 mmHg (1 mmHg = 0.133 kPa), currently controlled with nifedipine controlled-release tablets (30 mg once daily) with home self-measured blood pressure of 130-140/80-90 mmHg. Diabetes mellitus for 10 years, regularly taking dapagliflozin (10 mg once daily) for the past year, with monitored fasting glucose of 4-7 mmol/L, 2-hour postprandial glucose of 6-10 mmol/L, and HbA1c ≤ 6.5%. Dyslipidemia and history of cerebral infarction for 15 years; self-discontinued aspirin enteric-coated tablets and atorvastatin calcium tablets for the past three years. Denied history of tuberculosis, malaria, hepatitis B, or other viral hepatitis infections; denied other tumor or medical histories.

Personal History: Allergic to iodinated contrast agents. Denied long-term use of health supplements or traditional Chinese patent medicines. Smoking history of 40 years, averaging 20 cigarettes daily, quit one year ago. Alcohol consumption history of 30 years, primarily strong liquor (≥ 42% alcohol), 200-250 g per occasion, 7 times per week, reduced to 50-100 g daily in the past year. Former office worker, now retired. Preferred salty diet, minimal exercise, harmonious family relationships, good economic status.

RICE Assessment: The patient presented with abnormal liver function, attributing it to alcohol consumption, concerned about liver function changes and worried about developing liver cancer, expecting definitive diagnosis and standardized treatment.

Family History: Parents, spouse, and one son are all healthy. Denied family history of hepatitis or infectious diseases, tumors, or genetic diseases.

1.1.2 Objective Examination (O)

Physical Examination: Height 172 cm, weight 80 kg, BMI 27.0 kg/m², waist circumference 106 cm, blood pressure 137/88 mmHg. Normal development, good nutrition, clear consciousness, chronic disease facies, normal expression, voluntary position, normal gait, cooperative examination. No liver palms or spider nevi. No obvious jaundice of skin or sclera. No thyroid enlargement. Clear breath sounds in both lungs, no dry or moist rales. Regular heart rhythm, heart rate 72 beats/min, no murmurs. Soft abdomen, no tenderness or rebound tenderness. Liver and spleen not palpable below costal margins. Negative shifting dullness. Normal muscle strength and tone in all limbs. No lower extremity edema. Bilateral dorsalis pedis pulses diminished. Normal plantar temperature, tactile, and pressure sensation. Negative flapping tremor. Negative ankle clonus.

Auxiliary Examinations: See Table 1.

Table 1 [TABLE:1] The changes of metabolic indexes in the two years before the visit

[Table content preserved as in original]

Electrocardiogram: Sinus rhythm, normal ECG. Abdominal Ultrasound: Severe FLD. Body Composition Analysis: Body fat percentage 24.3%, muscle mass 55.7 kg, basal metabolic rate 6,740 kJ/1,611 kcal; "standard" body type. Liver Elastography: Controlled attenuation parameter (CAP) value 305 dB/m, liver stiffness measurement (LSM) 13.6 kPa, indicating severe hepatic steatosis and advanced liver fibrosis. Carotid Ultrasound: Carotid plaque with bilateral stenosis, possible right-sided occlusion.

1.1.3 Assessment (A)

Risk Factors and Health Issues: The patient has multiple coexisting risk factors including hypertension, diabetes, dyslipidemia, and carotid stenosis, with health issues such as cardiovascular and cerebrovascular diseases. The overall risk assessment for atherosclerotic cardiovascular disease (ASCVD) in Chinese adults is classified as extremely high risk, requiring urgent control of metabolic components and active management of chronic diseases. Calculated alcohol consumption was 470.4 g/week (for the first 30 years) and 235.2 g/week (in the past 1-2 years), exceeding 210 g/week, indicating excessive alcohol consumption requiring intervention; continued smoking cessation support needed. Patient Health Questionnaire-9 (PHQ-9) score was 2 (normal); Generalized Anxiety Disorder-7 (GAD-7) score was 2 (normal); Morisky Medication Adherence Scale-8 (MMAS-8) score was 4 (low adherence); Chronic Disease Self-Management Study Measures (CDSMS) score was 21 (poor self-management), with irregular follow-up visits, requiring adherence intervention. Family Resources: The patient has harmonious family relationships, good economic status, and family members willing to supervise treatment.

Based on auxiliary examination results, preliminary diagnoses include: FLD with high risk of liver fibrosis, Grade 3 hypertension (very high risk), type 2 diabetes mellitus, dyslipidemia, central obesity, hyperuricemia, metabolic syndrome, old cerebral infarction, and carotid artery stenosis.

1.1.4 Management Plan (P)

Medication: Aspirin enteric-coated tablets (100 mg once daily) for antiplatelet therapy; rosuvastatin calcium tablets (10 mg once daily) combined with ezetimibe tablets (10 mg once daily) for intensive lipid-lowering; nifedipine controlled-release tablets (60 mg/tablet, once daily) for blood pressure control; and dapagliflozin (10 mg once daily) for glucose lowering. Monitor blood pressure and glucose during treatment.

Referral: The patient has high risk of liver fibrosis, meeting FLD referral criteria (FIB-4 index > 2.67; LSM 13.6 kPa > 12 kPa). Referral to a tertiary hospital hepatology department is indicated for definitive diagnosis and treatment adjustment.

Patient Education: Guided by the Knowledge-Attitude-Practice theory and using motivational interviewing techniques, the intervention aims to enhance the patient's awareness of abnormal liver function and overall health status, strengthen beliefs in active intervention for multiple conditions, and develop actionable plans while the patient maintains subjective motivation to intervene in disease progression.

1.2 Referral Record

After referral to the tertiary hospital hepatology department, laboratory tests revealed: C-reactive protein 11.3 mg/L; alanine aminotransferase 19 U/L, aspartate aminotransferase 34 U/L, total bilirubin 18.3 μmol/L, direct bilirubin 6.7 μmol/L, albumin 38.6 g/L; creatinine 78 μmol/L, estimated glomerular filtration rate (eGFR) 87.6 mL·min⁻¹·(1.73 m²)⁻¹, potassium 4.15 mmol/L; triglycerides 2.52 mmol/L, total cholesterol 6.74 mmol/L, high-density lipoprotein cholesterol (HDL-C) 0.92 mmol/L, low-density lipoprotein cholesterol (LDL-C) 5.03 mmol/L; uric acid 436 μmol/L. Liver elastography: CAP 331 dB/m, LSM 15.2 kPa. Magnetic resonance imaging for liver fat measurement showed a relatively smooth liver surface, heterogeneous signal reduction in liver parenchyma on out-of-phase T1 imaging, and magnetic resonance elastography (MRE) approximately 3.439 (3.182-3.767) kPa, suggesting FLD, hepatic iron overload, and liver fibrosis. Liver biopsy pathology (Figure 1 [FIGURE:1]) showed steatohepatitis consistent with both alcoholic and metabolic etiologies. According to the NAFLD Activity Score (NAS): 2+3+2=7 points, fibrosis stage F2-F3; Steatosis-Activity-Fibrosis (SAF) score: S2A4F2-3. Immunohistochemistry: hepatitis B surface antigen (-), hepatitis B core antigen (-), CK7 (bile duct +), CK19 (bile duct +), MUM1 (few plasma cells +), CD34 (blood vessels and partial hepatic sinusoids +). Special stains: copper (rhodanine, -), iron (few hepatocytes and Kupffer cells +).

Comprehensive testing excluded viral and autoimmune hepatitis, confirming the diagnosis of "MAFLD combined with alcoholic liver disease, liver fibrosis, possible cirrhosis, steatohepatitis, Grade 3 hypertension (extremely high risk), type 2 diabetes mellitus, dyslipidemia, central obesity, hyperuricemia, metabolic syndrome, old cerebral infarction, hypoalbuminemia, carotid artery stenosis, and arteriosclerosis." Given the patient's "three highs," medications with potential hepatic benefits and improved cardiovascular and renal outcomes were prioritized. The treatment regimen was adjusted to: pioglitazone (30 mg once daily), dapagliflozin (10 mg once daily), semaglutide (once weekly, starting at 0.25 mg and gradually increasing to 1 mg), and telmisartan (40 mg once daily), while maintaining antiplatelet and lipid-lowering therapy. Home blood pressure and glucose monitoring were instructed.

Figure 1 [FIGURE:1] Liver biopsy with pathological section staining of patient. Note: A is HE staining (200×), B is HE staining (400×), C and D are Masson staining (200×).

1.3 Follow-up Record

After the patient was transferred back to the community, active follow-up was conducted within two weeks (May 6, 2024). Through shared decision-making, personalized comprehensive treatment goals were established: BMI 18.5-24 kg/m², waist circumference <90 cm; blood pressure <130/80 mmHg; fasting glucose 4.4-7.0 mmol/L, 2-hour postprandial glucose <10.0 mmol/L, HbA1c <6.5%; LDL-C <1.4 mmol/L, triglycerides <1.7 mmol/L, total cholesterol <4.5 mmol/L; normalization of abnormal liver enzymes; and no significant increase in liver stiffness index. The patient received lifestyle interventions including diet and exercise, plus comprehensive management of weight and adherence.

1.3.1 Lifestyle Intervention

Dietary Intervention: A calorie-restricted balanced diet was implemented, reducing total daily energy intake by 10-30% compared to weight maintenance requirements while ensuring adequate protein, fat, carbohydrates, vitamins, and minerals. Principles include: choosing healthy fats (olive oil, fish oil) and limiting saturated fats; encouraging whole grains and high-fiber carbohydrates while reducing refined sugars and white flour products; adequate dietary fiber intake for satiety; sufficient hydration to support metabolism and reduce appetite; portion control using small plates to avoid overeating; and limiting salt to <5 g daily. Recommended daily energy intake was 1,200-1,400 kcal, with protein comprising 15-20% (84-112 g), fat 20-25% (44-55 g), and carbohydrates 50-60% (150-168 g) of total calories. A personalized dietary prescription is shown in Table 2 [TABLE:2].

Exercise Intervention: Combined aerobic and resistance training was prescribed based on patient preferences (Table 3 [TABLE:3]) to promote long-term exercise habit formation.

Table 2 [TABLE:2] Dietary prescriptions for patients
[Table content preserved as in original]

Table 3 [TABLE:3] Exercise prescription for patients
[Table content preserved as in original]

Alcohol Cessation Intervention: The dangers of alcohol consumption were emphasized using the "5A" technique (Ask, Advise, Assess, Assist, Arrange) to support abstinence.

Sleep and Psychological Intervention: The patient was advised to ensure adequate sleep (≥7 hours daily) and avoid staying up late. Mental health monitoring was recommended, with cognitive behavioral therapy and relaxation training for anxiety or depression.

1.3.2 Supportive Management Measures

Health Education: Education covered MAFLD and liver fibrosis knowledge (etiology, symptoms, complications, treatment), emphasizing the importance of lifestyle intervention (diet, exercise, alcohol cessation, mindset). Medication guidance included proper dosing, avoiding self-adjustment, and monitoring for changes requiring medical attention.

Self-Management Enhancement: The patient was required to maintain records of lifestyle implementation, with family involvement for support and supervision.

1.3.3 Efficacy Evaluation and Follow-up Plan

Biochemical indicators (liver and kidney function, lipids, glucose) should be checked every 3-6 months; blood routine, upper abdominal and carotid ultrasound every 6-12 months; body composition analysis annually; and FIB-4 index or transient elastography annually to monitor fibrosis progression. Health records were updated with continuous follow-up at the community fatty liver clinic: every 2 weeks initially, monthly after stable condition, every 3 months after achieving lipid and blood pressure targets, and annual comprehensive assessment.

1.4 Subsequent Follow-up Results

Based on the Transtheoretical Model of Behavior Change, stage-specific intensive interventions were implemented: biweekly follow-ups during the initial intervention phase, adjusted to monthly after 2 months of stable condition, then to every 3 months after 3 months of comprehensive management when glucose and blood pressure targets were consistently met. No significant symptoms or adverse drug reactions were reported during follow-up. Given available family resources, family members were involved throughout the intervention to reinforce implementation.

Recent Follow-up (8th visit, after 8 months of comprehensive treatment): The patient maintained self-monitoring of blood pressure and glucose, performed aerobic combined with anaerobic exercise 3-5 times weekly for 20-30 minutes each session. MMAS-8 score improved to 7.5 (markedly improved adherence); CDSMS score increased to 48 (significantly enhanced self-management). Clinic blood pressure was 125/71 mmHg (target achieved); recent fasting glucose 5.3 mmol/L, 2-hour postprandial glucose 7.6 mmol/L (target achieved), HbA1c 5.5%, weight reduced to 73.9 kg, BMI 25.0 kg/m², waist circumference 94 cm (significantly decreased, not yet at target). Liver elastography showed CAP median 296 dB/m and LSM 10.1 kPa (significant improvement in FLD severity). The patient expressed high satisfaction with treatment outcomes. Semaglutide was discontinued, maintaining dapagliflozin monotherapy for glucose control, with unchanged antihypertensive, lipid-lowering, and antiplatelet therapies. The patient was advised to continue alcohol abstinence and current lifestyle modifications, further enhance self-management, maintain regular community follow-up, and continue monitoring.

2.1 Current Status of FLD Hierarchical Diagnosis and Treatment System Construction

With the gradual improvement of medical alliances and integrated healthcare systems, China has made significant progress in chronic disease hierarchical diagnosis and treatment. However, FLD has not yet been incorporated into the national primary chronic disease prevention and control framework, and a scientific, orderly two-way referral system remains incomplete. Community health institutions serve as the main venues for FLD screening and assessment, bearing core responsibilities for early diagnosis, risk stratification, and follow-up management. Domestic scholars have proposed constructing a "family-community-hospital" stratified, whole-course management model, with multidisciplinary specialists participating in family doctor contract teams to co-manage FLD patients with general practitioners. Through staff training, two-way referral coordination, case discussions, and community specialist clinics, this model strengthens generalist-specialist collaboration, implementing "primary care first visit, initial screening, stratified referral, and convenient follow-up" for comprehensive health management, aiming to achieve a closed-loop pathway from health screening to multidisciplinary diagnosis and treatment to community follow-up management, providing more precise and efficient medical services.

2.2 Therapeutic Inertia in "Three Highs" and FLD Management

Therapeutic inertia refers to the failure to initiate or adjust treatment in a timely manner, resulting in poor disease control. Primary care physicians exhibit significant therapeutic inertia in managing both FLD and the "three highs." A 2021 Dutch cohort study of 6,400 hypertensive patients found 87% experienced therapeutic inertia. A 2023 systematic review of 575,067 type 2 diabetes patients revealed over 50% of clinicians demonstrated therapeutic inertia in diabetes management. The situation is more severe in China, with one study by Li Dianjiang et al. finding 93.96% of primary care physicians showed therapeutic inertia in managing type 2 diabetes. Interestingly, most primary care physicians are unfamiliar with the term "therapeutic inertia" and its implications, with some denying responsibility and attributing poor outcomes to patient non-adherence after learning its definition. A US study suggested that specialty clinics managing type 2 diabetes had less therapeutic inertia than internal medicine clinics, possibly due to more integrated and coordinated healthcare systems.

Compared with the "three highs," therapeutic inertia in FLD management may be even more severe, with more pronounced deficiencies at physician, patient, and healthcare system levels. Main manifestations include insufficient diagnostic tools and lack of effective medications at the medical level; low patient awareness and poor adherence at the patient level; and lack of effective management systems and protocols at the healthcare system level. Table 4 [TABLE:4] summarizes common causes and coping strategies for therapeutic inertia.

Table 4 [TABLE:4] Common causes of treatment inertia and coping strategies
[Table content preserved as in original]

2.3 Advantages of General Practitioners in FLD Management and Diagnostic Workflow

General practitioners' advantages in FLD management center on early identification and comprehensive management, effectively addressing therapeutic inertia. Since FLD patients are often asymptomatic, identification depends on timely screening and assessment of high-risk populations. High-risk groups including obesity, type 2 diabetes, metabolic syndrome, excessive alcohol consumption, and asymptomatic transaminase elevation should be screened for FLD and fibrosis. In this case, the patient had "three highs" and asymptomatic transaminase elevation, leading to detection of possible liver fibrosis through abdominal ultrasound and FIB-4 index. Liver elastography confirmed referral criteria, and the patient was transferred to a higher-level hospital where liver MRI and biopsy confirmed "MAFLD combined with alcoholic liver disease." After treatment adjustment, the patient returned to community management, demonstrating the advantages of hierarchical diagnosis and treatment.

FLD is characterized by long disease course and slow treatment response, with diet and exercise modification remaining first-line therapy requiring full participation from general practitioners to develop scientifically sound management protocols. Currently, general practitioners lack systematic, comprehensive diagnostic protocols and integrated management models for complex cases like "three highs" combined with FLD, resulting in insensitivity, under-recognition, difficulty intervening, and poor follow-up. In this case, the general practitioner implemented comprehensive whole-course management including individualized treatment goal setting, coordinated care, combination pharmacotherapy, lifestyle management, intensive alcohol cessation intervention, health education, self-management capacity building, family involvement, and close follow-up, resulting in significant improvement and target achievement for multiple indicators. The management process applied the RICE principle for consultation, motivational interviewing to mobilize patient initiative, Knowledge-Attitude-Practice theory to optimize adherence, and the Transtheoretical Model to strengthen execution, ensuring effective intervention. This case fully leveraged primary care initiative through coordinated community and tertiary hospital management, generalist-specialist collaboration (Figure 2 [FIGURE:2]), demonstrating high patient satisfaction and effective management outcomes.

Figure 2 [FIGURE:2] Community comprehensive management model for "three highs" patients with fatty liver disease
[Figure content preserved as in original]

This article provides a case demonstration for primary care general practitioners managing patients with "three highs" and fatty liver disease. First, it optimizes a standardized general practice hierarchical pathway for screening, risk assessment, and two-way referral. Second, it explores a whole-course management framework for typical multimorbidity centered on general practitioners. Finally, this case analysis reveals therapeutic inertia among primary care physicians managing such patients and addresses insufficient patient awareness and physician inertia through adherence intervention, family involvement, and shared decision-making.

This single case report has limited sample representativeness. While it can enhance primary care physicians' awareness of fatty liver disease, its impact on improving disease prevention, screening, diagnosis, and treatment capabilities is limited, as is its effect on optimizing community management models and promoting whole-cycle health management for FLD patients. Future work will further promote and validate this protocol and pathway to construct a general practitioner-centered, whole-course, comprehensive management pathway for such patients.

In summary, early identification and assessment are crucial for patient outcomes in FLD combined with "three highs," and comprehensive management represents an effective intervention. The integrated management model explored in this case proved highly effective, with significant improvement in FLD and "three highs" related indicators. This management model warrants further promotion and application.

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Author Contributions: LI Jie conceptualized the article, designed the case presentation, proposed the concept of therapeutic inertia, and drafted the manuscript. YANG Xinhui contributed to conceptualization, designed the case presentation, proposed the comprehensive management plan and pathway, and drafted the manuscript. CAO Li collected and organized patient case data, test results, examination results, and pathology results. ZHANG Jing collected patient test results, examination results, and pathology results. JIANG Yue revised the final version and takes responsibility for the manuscript.

Conflict of Interest: The authors declare no conflict of interest.

ORCID IDs:
LI Jie: https://orcid.org/0000-0003-2915-7362
YANG Xinhui: https://orcid.org/0009-0003-2015-7398
CAO Li: https://orcid.org/0009-0006-3714-3672
ZHANG Jing: https://orcid.org/0000-0002-3082-8330
JIANG Yue: https://orcid.org/0000-0001-9595-623X

(Received: May 21, 2025; Revised: July 1, 2025)
(Editor: KANG Yanhui)