History Taking : Jaundice

History Taking Scenario

Your Role

You are the medical SHO at the Gastroenterology clinic and are asked to see the following patient

Re : A,age 56 years

Dear Doctor,

Thank you for reviewing this gentleman who was found to have a raised ALT at a routine blood test.

His ALT has remained persistently elevated at 80 on repeat testing with otherwise normal liver function tests.

Mr A gives a history of previous alcohol excess but I understand that he is now abstinent.

Examination is unremarkable,

I have sent a screen for viral hepatitis which has been negative.

Please advise on further investigation and management.

Yours sincerely

Dr X

Important aspects


Main points on approaching the scenario.

Greet the examiner

Read the scenario in the time given for reading utilizing the time to carefully read the history and focus on main points.

What is being asked in the history.


Is there a clue in the history to the underlying diagnosis?

Memorize the name of the patient carefully

Now approach the patient

Greet the patient

Introduce yourself : I am Dr Gillani

I have been asked to ask you a few questions to better understand your problem.

Ask the patient what does he mean by jaundice ?

Has he or anybody else noticed a change in color of their eyes,ie they appear more yellow than usual ?
Sometimes patient will tell of associated symptoms only.

Give time to patient to let them explain about all their associated symptoms because jaundice is frequently a serious illness and should not be ignored.
Clinical Sciences Made Simple
History of Present Illness :

I believe you have been feeling unwell recently.

When was the last time you felt completely healthy.

How have you been feeling since then ?

Would you want to tell what has been going on ?

Ask about onset and duration of disease.

Since when did you notice that your eyes / skin have changed their color ?

How have things been progressing since then ?

Acute onset (Days )

Gall stone disease ( Cholangitis, Choledocholithisis)

Acute Hepatitis

Acute Budd Chiari Syndrome

Haemolysis

Subacute Onset ( Weeks – Months )

Pancreatic and hepatobiliary malignancy

Intrahepatic cholestasis ( eg drug induced, Auto immune , Infiltrative liver Disease )

Right sided Heart Failure

Recurrent Episodes :

Gallstone Disease ( cholangitis , choledocholithiasis)

Disorder of Bile transport eg ( gilbert”s Syndrome )

Associated Symptoms :

Fever :

Occurs in

Cholangitis

Viral hepatitis

Cholecystitis

Alcoholic hepatitis

Mirizzi”s Syndrome : Compression of hepatic duct by chronic inflammation in Hartman:s pouch of the gall bladder)

Right Upper quadrant Pain :

This occurs in cholangitis
.
Acute Hepatitis

Budd Chiari Syndrome

Mirizzis Syndrome

Gradual onset painless chelestatic Jaundice :

This occurs in

Pancreatic duct malignancy

Bile duct malignancy

Auto immune cholestasis

Drug related cholestasis

Confusion

Presence of confusion or altered mental status is strobly suggestive of a serious underlying proble such as :

Sepsis due to Cholangitis or

Hepatic encephalopathy due to Acute or Chronic Liver Failure

Other causes include

Intracranial haemorhage due to coagulopathy caused by Liver failure

Hypoglycemia due to Liver Failure

Or Post ictal state following seizure due to Alcohol or Substance Withdrawal

Mucosal Bleeding / bruising :

Ask specifically about gingival bleeding , nose bleeds and easy bruising.

Apart from coagulopathy caused by liver failure,other causes of mucosal bleeding and jaundice

include : DIC : Disseminated Intravascular coagulation due to cholangitis and sepsis,

Thrmobocytopenia due to portal hypertension ( Hypersplenism)

Thrombotic Thrombocytopenic purpura ( TTP) or

Severe Malaria

Back pain

can occur in Viral hepatitis along with Right Upper Quadrant pain and Severe Haemolysis.

Dark Urine and Pale stools

These are Classic symptoms of Obstructive Jaundice.

This occurs due to excess conjugated bile appearing in the urine.

Also lack of conjugated bile secreted into the intestines lead to a lack of stool pigment ( pale stools)

However severe haemolysis may cause dark urine due to haemoglobinuria.

Therefore,these questions may be better at following the progress of jaundice once the diagnosis is known rather than distinguishing obstructive jaundice from haemolysis.

Pruritis is a feature of all cholestatic processes including bile duct obstruction,drug induced and auto immune.

Other systemic diseases causing pruritis include :

Chronic Renal Disease

Haematological malignancy

Thyrotoxicosis

Weight Loss

Involuntary weight loss is associated with Pancreatic or Hepatobiliary Malignancy.

Patients with advanced Chronic Liver Disease are aso usually malnourished although their weight loss may be balanced by the development of ascites.

Associated Risk Factors :

Needle and Blood exposure :

Shared needles / iv drug abuse

Tattoos

Piercings

Dental or medical care abroad

Sexual History :

Ask sensitively about Sexual contacts ( Type of encounter : Heterosexual or Homosexual)
Number of partners

Use of barrier protection ?

Exposure to Hepatitis A

Drinking contaminated water ?

Exposure to individuals with viral illness

History of eating shell fish

Travel history in last 6 weeks ?

Recent Immunusuppression :

Patients who may be asymptomatic carriers of hepatitis B may develop liver failure due to viral reactivation after starting immunosuppressant therapy eg steroids and chemotherapy/.

Risk factors for Alcoholic Hepatitis and Acute Liver Failure

Alcohol Intake

Ask patient openly about Alcohol Intake

How much alcohol do you drink in an average weekend ?

Would you say you drink about one to two beers / whiskies a night or 8 – 10 beers / whiskies a night.
A lot of people feel alcohol helps them sleep at night . Do you feel the same ?

Now may be a good time to ask about CAGE Questionaire :

CAGE Questionnaire “CAGE” is an acronym formed from the italicized words in the questionnaire (cut-annoyed-guiltyeye).

The CAGE is a simple screening questionnaire to id potential problems with alcohol.

Two “yes” responses is considered positive for males; one “yes” is considered positive for females.

Please note: This test will only be scored correctly if you answer each one of the questions.

Please check the one response to each item that best describes how you have felt and behaved over your whole life.

Have you ever felt you should cut down on your drinking? __Yes __No

Have people annoyed you by criticizing your drinking? __Yes __No

Have you ever felt bad or guilty about your drinking? __Yes __No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? __Yes __No


Offer help networks to try giving up alcohol.

Medications History :

Try to establish if the patient has been taking any hepatotoxic medications such as paracetamol.

Ask about any history of clotting disorder which can cause Budd Chiari Syndrome.

Any past history of Gall stones of hepato biliary surgery ? ( Risk of biliary strictures)

Travel History

Ask about any travel to South Eaast Asia , Eastern Eurpe or Sub Saharan Africa where there is a chance pt might havr acquired Hepatitis A or B

Family History

Try to elicit a family history of diseases below :

Hepatitis

Blood Disorders

Haemochromatosis

Wilson”s Disease

Gilbert”s Syndrome

Haemolytic Anemia

G6PD Deficiency.

Vaccination for Hepatitis A and B

Gyne & Obs History :

Ask about history of pre-eclampsia and low platelets in previous pregnancies ( to establish HELPP Syndrome )

Address any concerns the patient might be having

Discussion with Examiner

Formulating a plan of Action

Explain to the patient that a full clinical examination,blood tests and an ultrasound scan of liver

would be necessary to further determine the underlying diagnosis.

The Blood Tests which need to be done include :

Full Blood Count

Urea and Electrolytes including EGFR and Creatinine

Serum Paracetamol Levels

ABGs in unwell patients

Liver Function Tests ( Bilirubin, Alkaline Phosphatase and Alanine Transaminase )

Hepatitis A IgM , B s Ag and C Ab Serology

Serum Albumin and Total Proteins


Clotting profile including PT APTT and INR

Liver Smooth Muscle antibodies / Auto antibodies : that include : Anti smooth muscle Abs / Mitochondrial LKS antibodies)

Serum Iron , transferrin , TIBC and Ferritin tests for Haemochrmatosis

Serum Ceruloplasmin levels for Wilson”s Disease

Liver Biopsy if needed.

Causes of Peripheral Neuropathy

Causes of a Peripheral Neuropathy :

Predominantly sensory

Common causes include :

Diabetes mellitus

Alcohol

Drugs – eg isoniazid and vincristine

Vitamin deficiency eg B1 and B 12

Predominantly motor :

Guillain Barre Syndrome and Botulism – present acutely

Lead toxicity

Porphyria

HSMN : Hereditary Sensori Motor Neuropathy

Mononeuritis Multiplex

Diabetes

Connective Tissue Disease eg  SLE and Rheumatoid arthritis

Vasculitis eg  PAN  : Polyarteritis Nodosa and CSS Churg Strauss Syndrome

Infection eg HIV

Malignancy

History Taking : Chest Pain

History taking Scenario

Your Role :

You are the medical SHO /RMO on call clerking in A & E and are asked to assess a young man with chest pain.

Your patient : T L , age 21

This young man presents with chest pain.He has been out clubbing with his friends on Saturday night and developed sudden onset of retrosternal chest pain radiating to the back with associated shortness of breath.

His father suffered from an MI at age of 50 years.

He is concerned that he is having an MI.

His Chest X ray shows a pleural effusion on right side.

The ECG shows a Sinus Tachycardia but is otherwise un remarkable.

Blood Tests are awaited.

Please take a detailed history from this patient keeping in mind the major differential diagnoses.

Main points and approach to the scenario:

Greet the examiners

Read the scenario carefully with focus on patients name ,age and presenting complaint.

Assess/ determine what is being asked from you in the scenario.

Take time to read the scenario fully in the required time frame.

Asssess the time you have to complete a focused and clear history and make sure you rule out the main alarming conditions first that present with chest pain.

For example in this scenario , Set Your objectives

You have to take a focused and comprehensive History to exclude the conditions below :

Differential Diagnosis:

Esophageal Rupture
Pulmonary Embolism
Aortic Dissection
Acute Myocardial Infarction
GORD : Gastroesophageal reflux disease
Acute Pancreatitis
Pneumothorax

Now Greet the patient and Introduce Yourself

History Of Present Illness

Take a detailed account of history of present illness following the format:

ODPARRA:

Onset
Duration
Progression
Associated Factors
Relieving Factors
Radiation
Aggravating Factors

Here is how to begin this station

Good Morning Mr L

My name is Dr AR and I am here to ask you a few questions to better understand the casue of your coming to the hospital today

Is it alright if I proceed?

Are you feeling comfortable ?

The above questions are important to ask as they constitute an important score in exam which is called Maintaining Patients Welfare.

So can you please tell me in your own words what brought you to hospital today ?

Listen carefully to what patients says noting any new points that were not present in patients history.

Onset :
Can you please tell how did the problems start?

Was it sudden in onset or have you been feeling it for some time and it got accentuated?

Duration:

How long this stay for.

Over what period of time did this happen.

If repetitive problem ,how long has this been happening ?

Is it constant or intermittent ?

Progression:

Did it get worse? Stayed the same ? or improved ?

Associated Factors :

Any nausea ,sweating , fever , vomiting ,sob : Cardiac

PND , orthopnea ,ankle oedema : Left ventricular failure.

Abdominal pain ?

Any trauma to chest etc

Any cough haemoptysis : PE and LRTI

Any unilateral swelling of leg DVT.

Any recent history of travel abroad ?

Cold/flu like symptoms : Pericarditis

Excessive drinking before the episode : Esophageal perforation

Radiation:

Any radiation of the pain somewhere eg back etc,

Aortic dissection, pancreatitis and peptic ulcer radiate to the back.

Cardiac ischaemic pain radiates to left jaw,neck and left arm.

Nerve root pain remains around the chest wall in a band like pattern.

Relieving factors :

Any thing that made it better eg medication , change in position etc

Analgesics : Musculoskeletal pain

Cardiac pain : rest and nitrates.

Antacids : GORD and PUD.

Aggravating Factors :

Any thing that made it worse?

Deep inspiration : pericarditis and respiratory.

Movement : Musculoskeletal.

Eating / after meals : peptic ulcer disease and GORD.

Bending forward : pericarditis.

Exertion ? Cardiac.

Family History of IHD , Hypercholesterolemia , Angina , Asthma ,MI , Hypertension , Epilepsy or bleeding disorders

Site of chest pain”

Cardiac : central and often radiates to left jaw neck and left arm.Is brought with exertion and may be associated with shortness of breath.

Respiratory : is usually present on site of pathology eg infection or pneumothorax.

Musculoskeletal : is present at site of pathology or injury

Peptic ulcer disease / GORD occurs in lower chest and epigastrium.

Nature of pain :

Cardiac / ischemic : Dull pressure like sensation.

Pericarditis and Respiratory : sharp and pleuritic.

Nerve root pain : band like shooting pain around the chest from the back to the front.

GORD : sharp and burning

Personal History

Any habitual smoking or drinking alcohol ?

Past Medical and Family history :

Cardiovascular risk factors :

Smoking , hypertension,diabetes,hypercholesterolemia and family history of these.

Any compliance to treatment

Previous MI or CABG / BYPASS etc

History of clotting / thrombotic disorders

Medications and their compliance

Occupational history

Assess the disability and impact on life

Address the patients concerns about this

Plan of Management :

Tell the patient the most likely Differental Diagnosis and other possible causes

In this case this seems like an Esophageal perforation but other D/D are:

Pulmonary Embolism
Aortic Dissection
Acute Myocardial Infarction
GORD : Gastroesophageal reflux disease
Acute Pancreatitis
Pneumothorax
Pleurisy
Pneumonia
Pericarditis

Further investigations will be needed to ascertain the cause eg

Chest X ray
ECG
Oxyge saturations
Full Blood Count
D- dimers
Arterial Blood gases
CTPA

Communication Skills : Breaking Bad News Scenario

Mr J  is a 68 years old male who has been having increasing shortness of breath,back ache and swelling of both feet since last 4 months.

He has been investigated now and it is found out he has Metastatic Renal Carcinoma and after discussion with oncologist ,he says it is not possible to treat it by Surgery and only symptomatic / Supportive Rx can be given.

He is also found to have Congestive Cardiac Failure . Oncologist thinks he has only 4 months to live.

Break this Bad News to him.

Key points :
Introduce your self and confirm identity of patient.

Establish purpose of meeting and also ask the patient what he knows about his condition,blood and imaging tests and other investigations.

Try to establish if he knows what the problem might be ?

“ Do you know the purpose of our meeting today ? “

“ What do you think is wrong with you ?”

“We did some tests and the results are back” .

“I am afraid the results are not too good “

“ Do you want me to proceed with the results? “

“ Do you want to know the results of these investigations ?

“ Do you want me to call someone from your home to accompany you ?


“ You have been diagnosed with cancer of the Right  kidney.

Offer some time for the patient to take this news before proceeding further.

Offer patients some tissues if possible.

Ask if he wants us to proceed further with more findings,if he wishes so ,tell him about his Metastasis finding .

“I am afraid the cancer has spread to other parts of your body from your kidney and the oncologist does not believe treatment of this cancer at this stage can be done ,neither surgery nor chemotherapy as it has widespread “.

But we will give you treatment for pain control and nausea .

Patient asks how much time do I have ?

Tell him ,the oncologist  says you have only 4 more months to live.

Be specific and clear and honest about predicted prognosis.

Patient said he wants to go on holiday.

Encourage him to enjoy his time by going to holiday and doing the things and hobbies he likes to do and encourage him to spend time with his family as well.

Ask about his hobbies and tell him to engage in them.

Also if he wants to have another meeting with his family present .

Tell him to avoid dangerous hobbies but can have safe one

Nervous System Examination Routine

NERVOUS SYSTEM EXAMINATION

Mr K is a 58 years old gentleman who has been having difficulty in walking.

Please examine the Neurological system and lower limbs of this patient.

How to approach the case

Greet the patient and introduce yourself.

Steps in Examination :

Aim to shake his hand.Once a candidate had a patient with Myotonic dystrophy in one of the exams.
When he shook his hand , he wouldn’t let go. He had myotonic dystrophy which the candidate failed to pick due to examination anxiety.

Tell him I am Dr S and I want to examine your legs.

If you are comfortable ,is it OK if I proceed with the examination?

Look at the face of the patient . Any particular facies ? ( e g mask like face )

Any Ptosis ?/ Droping of eyelid?

Any obvious cranial nerve palsy eg eye deviated out and down etc ?

Look at the back for Scoliosis , Scar marks , Winging of scapula etc ?

Look at the legs of the patient for any wasting , fasciculations , abnormal movements etc.

Gait :

Now ask the patient to get up and take a few steps forward to the wall and have a look at his gait.

At this point it would be great idea to walk close to the patient , supporting him in the event if he falls at all.

Now tell the patient to walk back aiming to test Tandem walking .

(Tandem gait is a gait where the toes of the back foot touch the heel of the front foot at each step. Neurologists sometimes ask patients to walk in a straight line using tandem gait as a test to help diagnose ataxia, especially truncal ataxia, because sufferers of these disorders will have an unsteady gait.)

Tell patient to stand up straight and close his eyes and support him. ( Romberg”s Test)

The Romberg test is used to investigate the cause of loss of motor coordination (ataxia). A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception. If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature, that is, depending on localized cerebellar dysfunction instead.

Tell the patient to walk back into the bed,supporting him

Tone

Now examine tone of the legs

Check for ankle clonus and plantars as well.

Power / Motor Examination

Examine the power of lower legs.

Sensory Examination

Now do a quick sensory examination and reflexes of the lower limbs including ankle and knee jerk.

Reflexes:

Plantars

Co-ordination

Examine co-ordination of the legs including heel knee shin test.

Cerebellar signs

Look for cerebellar signs including intention tremor and Disdiadochokinesis.

In sensory system examination,look for Pin prick,temperature ,joint position and two point discrimination.

If possible,do a fundoscopy / atleast mention it.

Aim to see if patient has a drug chart and taking any medications.

Diagnosis of the patient :

The patient had Ataxic gait .This is seen in patient having lesions of the central part of the cerebellum
Positive Romberg.

Romberg's test is positive in conditions causing sensory ataxia such as:

Vitamin deficiencies such as Vitamin B12

Conditions affecting the dorsal columns of the spinal cord, such as tabes dorsalis (neurosyphilis), in which it was first described.

Conditions affecting the sensory nerves (sensory peripheral neuropathies), such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP).

Friedreich's ataxia

Ménière's disease

History Taking : Shortness of Breath

Introduction 

My name is Dr A and I am here today to ask you a few questions about what brings you to hospital today.

I believe you have been having increasing shortness of breath.

Would you be able to tell me in more detail about it so we can try to find out t he possible causes for this.

History of present Illness

ODPARRA

Onset :

Can you please tell me how did the problem start?

Did it happen suddenly or over a period of time ?

Establish a baseline functional status : What was your breathing like about 6 months ago ?

Is the breathlessness constant or intermittent ?

If intermittent , how frequently do you experience breathlessness ?

Duration:

How long has this been going on for?

Is it the first time you have experienced this or has it happened before?

Progression:

Is it getting worse with time ? or staying same or improving ?

Aggravating Factors :

What worsens your shortness of breathlesness.

Is it present at rest ?

Does exertion make it worse ?

Does it get worse on lying down ?

Relieving Factors :

Does it get better with rest ?

Do any medications make it better ? eg nebulizers,inhalers or sub lingual nitrates ?

Associated Factors

Any chest pain ?

This is suggestive of ischemic / cardiac origin.

Any palpitations :

They indicate presence of underlying arrhythmia which can be exertional and would mean : AF / atrial flutter or ventricular arrhythmias.

Ask the patient is their heart beat regular or irregular during arrhythmia and if they could tap out the beat.

Also if they have measured their heart beat.

Any Orthopnea or PND: Paroxysmal Nocturnal Dyspnea are suggested of left Ventricular Dysfunction.

Peripheral oedema is suggestive of CCF or Cor – pulmonale.

Respiratory symptoms :

Any cough ? Dry or productive,

Any wheeze , Any Haemoptysis ?

If productive color of sputum and amount

A dry non- productive cough suggests viral etiology,or Interstitial lung disease

A productive / suppurative cough is suggestive of infection,suppurative lung diseases or malignancy.

Haemoptysis occurs in malignancy , PE or infection or pulmonary congestion especially with mitral stenosis

Any exceesive use of steroids ( eg Asthma or Rheumatoid arthritis causing immunusupression leading to PCP pneumonia )

Vasculitic symptoms and Sarcoidosis

Any leg pains

Any skin rash

Muscle aches suggestive of vasculitis

Any increased use of steroids ( can cause pneumocystis carinii pneumonia )

Any History of HIV / Immunosuppression ( can cause pneumocystis carinii pneumonia )

Any cold , fevers  : Any flu like symptoms :Viral etiology

Any weight loss : Malignancy / TB

Do you keep any pets : Psittacosis / allergic bronchitis

What is your occupation : Occupational lung disease : Do symptoms improve when away from work ?

Any irritation in eyes

Any swollen glands ? ( lymphadenopathy) : TB / Sarcoidosis / Malignancy

Any recent contact with some one with TB

Any change in bowel habits

Any blood in stools

Ay Jaundice ( Yellow discoloration of eyes/ sclera)

Any recent travel abroad

Any use of Recreational drugs : or IV abuse ( HIV / Hepatitis B / Immunosuppression )

Medications :

Ask about full list of medications and compliance to therapy.

Appetite suppressors eg fenfluramine is associated with pulmonary hypertension.

Social Issues :

Ask about smoking ( cigarettes / day and pack years)

Alcohol consumption

Occupation

Impact of symptoms on daily living.

Any concerns the patient may be having ?