Jaundice

Question 1

Sequence of events

Answer 1

Open- tell me about what’s been happening
Timeline- when did it start and how has it progressed?
Timing- has it happened before?
Exacerbating factors- made worse by anything eg. Not eating

Question 2

Associated Sx

Answer 2

FWARJNL Tiredness (anaemia) 
GI- abdominal pain, encephalopathy (confused), ascites, foreign travel in last 6 months, itchy skin (often begins before jaundice), change in stool habit? Dark urine? 
Pain- if yes do Socrates

Question 3

Alcohol screening- CAGE questionnaire

Answer 3

How much do you drink in a week? Is this typical for you? Do you ever binge? If so, how often?

CAGE;

Have you ever felt you should cut down
Have other people annoyed you by commenting on your drinking
Have you ever felt guilty regarding how much you drink
Have you ever had a drink in the morning to settle yourself

Maybe do this when asking about alcohol

Question 4

PMH

Answer 4

Recent illness- people with Gilbert’s syndrome become more jaundiced during times of illness or stress

Question 5

Pre hepatic jaundice

Answer 5

Gilbert’s syndrome (congenital hyperbilirubinaemia)

Haemolysis eg, G6PD deficiency

Question 6

Hepatocellular jaundice

Answer 6

Alcoholic hepatitis 
Viral eg. Hep A B C, EBV 
Drug induced hepatitis 
Autoimmune hepatitis 
Cirrhosis 
HCC
Metastases 
Wilson’s disease 
Hepatic congestion from cardiac failure

Question 7

Cholestatic jaundice

Answer 7

Gallstones
Head of pancreas cancer
PBS
PSC

Question 8

Patients perspective

Answer 8

Feeling and effect on life
Ideas
Concerns
Expectations

Question 9

PMH

Answer 9

Liver disorder, previous cancer, surgery, autoimmune conditions

Question 10

DH

Answer 10

Regular medications and any changes

Allergies

Question 11

FH

Answer 11

Conditions run in the family

Any FH of jaundice

Question 12

SH

Answer 12

Smoke alcohol recreational drugs
Work
Home
Sexual history (viral hepatitis)

Question 13

Tip

Answer 13

Try and show the examiner that you are looking at pre, hepatic, and post causes

Question 14

Gilbert’s syndrome

Answer 14

Most common
Jaundice at any time of a viral illness
Crigler najjar is another more sever congenital hyperbilirubinaemia
Unconjugated= stools and urine normal (differentiate from viral hepatitis for example)

Question 15

Malaria

Answer 15

Fever myalgia headache malaise at least 6 days after transmission

Question 16

Haemolysis

Answer 16

Autoimmune haemolytic anaemia, hypersplenism etc.

Question 17

Hepatocellular carcinoma

Answer 17

Secondary to chronic Hep B or C infection

Also secondary to alcoholic hepatitis, PBC hereditary haemachromatosis

Question 18

Metastatic disease from other primary site

Answer 18

Colorectal, lung, breast, pancreas, stomach, melanoma etc.

Question 19

Pancreatic carcinoma

Answer 19

Painless jaundice (think HCC too)

Question 20

Gallstones

Answer 20

5 F’s
Painful
Only jaundice if they obstruct the common bile duct

Question 21

Investigations

Answer 21

FBC UE LFT liver screen (viral serology and autoimmune) blood film (malaria)
Liver USS and CT abdomen
MRCP (gall stones)

Question 22

Wilson’s disease

Answer 22

Copper accumulates in bodily tissues

Question 23

Viral hepatitis

Answer 23

Consider asking about sexual history/ IVDU/ travel abroad to rule in/out viral hepatitis

Question 24

Paediatric jaundice

Answer 24

Before 24 hours- pathological
Usually 2-14 days
Breastfeeding, may persist for several weeks (emphasise that the health visitor should be checking on this/may need blood tests to monitor bilirubin levels/safety net and any concerns- get medical assistance)

Causes- physiological (prematurity/breastfeeding can exaggerate this)/biliary atresia/hypothyroidism (ask mum about thyroid problems)/haemolytic anaemia (G6PD)